Handbook of Rectal Diseases S. H. M. H _ 1. H A PLATE I. THE BLOOD VESSELS OF THE RECTUM. S. H. Superior haemorrhoidal artery. M. H. Middle haemorrhoidal artery. L. H. Inferior haemorrhoidal artery. A. Anus. E. S. External sphinc- r muscle. P. D. Pelvic diaphragm. P. Cut edge of peritoneum. The Kcctuni: Its Diseases and Developmental Defects, by Sir Charles Ball. ,UE ' OF CGLLE'- EGFATK L Hand Book OF Diseases of the Rectum 7 BY LOUIS J. HIRSCHMAN, M. D. DETROIT, MICHIGAN, U. S. A. FELLOW AMERICAN PROCTOLOGIC SOCIETY; LECTURER ON RECTAL SURGERY AND CLINICAL PROFESSOR OF PROCTOLOGY, DETROIT COLLEGE OF MEDICINE; ATTENDING PROCTOLOGIST. HARPER HOSPITAL; CONSULTING GYNE- COLOGIST, DETROIT GERMAN POLYCLINIC; COLLABORATOR ON PROCTOLOGY, "PHYSICIAN AND SURGEON"; EDITOR "HAR- PER HOSPITAL BULLETIN"; CHAIRMAN SECTION ON SURGERY, MICHIGAN STATE MEDICAL SOCI- ETY; EX-PRESIDENT ALUMNI ASSOCI- ATION, DETROIT COLLEGE OF MEDICINE, ETC., ETC. WITH ONE HUNDRED AND FORTY-SEVEN ILLUSTRATIONS, MOSTLY ORIGINAL, INCLUDING TWO COLORED PLATES. St. Louis, C. V. MOSBY MEDICAL BOOK & PUBLISHING CO. 1909 Yfl/AflSU / BTcC 10 -303JJOO COPYRIGHTED BY C. V. MOSBY Co., 1909. TO THE MEMORY OF MY FATHER, FREDERICK LOUIS HIRSCHMAN, M. D., A country doctor ivhose untimely death ivas a sacrifice to the duties of that overworked and wholly unappreciated class of our pro- fession the Country Doctor: this zvork is affectionately dedicated by THE AUTHOR /fr J /r vulva, is a frequent accompanying symptom of many anal and rectal diseases. In fact it may occur with any of them. The degree and severity of the itching varies from a slight feeling of uneasiness and irritation, a mild prick- ing sensation following stools, to the most intense, per- sistent, aggravating condition characteristic of the more severe types of pruritus ani. Many constitutional dis- eases, such as Diabetes, and Uric acidosis predispose the patient to itching of any part of the body. When such a patient has a diseased condition of any part of the ano-rectal region, however slight, he usually develops pruritus ani in addition to his other symptoms. In the author's experience, almost every case showing itching as the predominating symptom has been demonstrated to PROTRUSIONS ELEVATIONS. 37 have had its origin in some local diseased condition of the ano-rectal region. Protrusions. While the most common protrusion of which the patient complains is some variety of hemor- rhoids ; it should be born in mind that there are several other conditions made manifest by protrusion at the anal orifice, among which may be mentioned : Prolapsus, Poly- pi, Hypertrophied Papillae, and Cancer. In questioning a patient regarding a protrusion, one should find out whether they appear with stools or not ; and whether or necessary to produce it, or whether it appears sponta- neously; whether it can be replaced, and if so, whether easily or not. One should inquire as to their number, whether they appear with stools or not ; and whether or not their appearance or replacement is accompanied by pain. Elevations found in the peri-anal region may be smooth and rounded ; rough, hard, or soft and fluctuating ; and are caused by external hemorrhoids, abscesses, lipo- mata, condylomata, or the external openings of fistulae. A rounded elevation occurring at one side of the anus, accompanied by pain of a throbbing character with some rise of temperature, will be found due to a marginal or ischio-rectal abscess. A hard, rounded protruberance, occuring suddenly at the anal margin, accompanied by intense throbbing pain, will be found to be an acute thrombotic external hemorrhoid. A cluster of small, rough elevations at the anal opening, usually posterior, is the most common manifestation of condylomata. A small papular elevation anywhere in the peri-anal region from which a purulent discharge exudes, is al- most invariably the external opening of a fistula. 38 DISCHARGE CONSTIPATION DIARRHOEA. Discharge. A history of discharge from the anus should always suggest a proctoscopic examination. Hemorrhage has already been described above. While mucus may be caused by any irritation, acute or chronic, and accompanies practically all forms of rectal disease; it may originate in some inflammatory condition of the colon. The sigmoid should therefore always be explored when a mucous discharge is met with. Purulent dis- charge may come from colitis, but more often points to abscess, blind internal fistula, rectal ulceration, or malig- nant disease. The odor which accompanies the dis- charge caused by the last mentioned condition, is almost diagnostic in itself. Many patients who complain of pru- ritus, or local irritation of the anal region, will also com- plain of the moisture of the parts. It is well to bear in mind the possibility of disease of the Morgagnian crypts as the origin. of this symptom. Constipation. No case of constipation, particularly of the chronic variety, should ever be treated until a complete examination has been made. So many cases of so-called constipation, which is purely a functional con- dition, are in reality due to mechanical causes. Ente- roptosis, floating kidney, prolapse, stricture, hypertro- phied rectal valves, enlarged prostate, uterine displace- ments, adhesions, rectocele, perineal lacerations, fecal impaction, and many other diseased conditions, often act in a purely mechanical way, causing obstipation, which can only be discovered after proper examination. Diarrhoea. Chronic diarrhoea per se, or alternating with constipation, so frequently occurs as a symptom of carcinoma and ulceration, that these diseases should be excluded by examination before treatment is commenced. ALTEKED STOOLS SACRAL BACKACHE SHOOTING PAINS. 39 Persistent diarrhoea, unaccompanied by pain, occurring in an apparently healthy individual, is very suggestive of beginning malignant disease. Altered Stools. Deviations in the normal appear- ance of the stools are often very suggestive. The large, hard stool of prolonged fecal retention, giving a vastly different meaning than the narrow tape-like or pipe-stem stool of stricture. The color, consistency and amount of the stool, as well as the appearance of blood, pus, or mucus with the movement, as has been noted above, are all of importance. Sacral backache is often the only subjective symptom of beginning malignant disease. It often accompanies in- ternal hemorrhoids, prolapse, impaction, and various benign growths. It is a symptom which should always call for rectal examination. Many obstructive conditions of the sigmoid, as well as sigmoiditis, and fecal impac- tion, will often cause a sense of weight or constriction in the pelvis. When this occurs in females, and disease of the uterus or adnexa are excluded by gynecological exam- ination, the sigmoidoscope should be used. Shooting pains down the limbs, particularly the left, may accompany all forms of rectal disease. Sciatica has been so perfectly simulated by rectal ulcer that diagnos- ticians have repeatedly been led astray. This is often the predominating symptom in lateral ulcer of the rec- tum. Ischio-rectal abscess, particularly of the left fossa, frequently causes pains shooting down the limbs. Crampy, painful, and scanty menstruation occur- ring in women who have perfectly normal genital organs will be found upon rectal examination to be due in many 40 PAINFUL URINATION ANEMIA FOREIGN BODY. cases to ulceration of the anterior rectal wall, fissure, or hemorrhoids. Frequent and painful urination, pressure symptoms in the bladder, pain and burning at the vesical neck, enuresis : all may be due to a number of anal and rectal diseased conditions. Fissure and ulcer are the most frequent causes of .bladder irritability. Loss of appetite, impaired digestion, nausea, headache, sallow complexion, and fever are frequently some of the symptoms of an auto-intoxication caused by some inter- ference with the functions of the lower bowel, whose cause will be found upon rectal examination. Anemia. Persons suffering from anemia should al- ways be questioned as to the existence of rectal hemor- rhage as not infrequently the loss of blood from internal hemorrhoids, or ulceration is so extensive as to account for the anemic condition. Restlessness in Children. When children are restless at night and are continually picking at the nose or scratching the anus or genitals, an examination of the rectum will often disclose the presence of pin worms. Foreign Body. The history of the swallowing of a foreign body such as a pin or a fish bone, followed in a few days by anal pain or tenesmus, should call for a rectal examination, and the offending cause of the trou- ble will be found not infrequently protruding from the mouth of one of the Morgagnian crypts. CHAPTER III EXAMINATION OF THE PATIENT. The first and most important, consideration is the loca- tion and arrangement of the examining room. The ideal suite of offices should include besides a reception room, a consultation room, an examining or operating room, and a resting or recovery room. These two latter rooms should be situated at some distance from the reception room and should be separated from the other rooms by walls which are sound proof. It is not a pleasant pros- pect for a patient in the reception room nervously await- ing his or her turn, to overhear through flimsy plaster or glass partitions, the recital of another's ailments, or the weeping of a hysterical patient on the operating table. TVhere a glass partition is all that separates the operating room from the reception room, those in waiting are often treated to a shadowgraphic representation of the per- formance going on within. One who expects to do minor surgery or treatment work should equip himself properly for the same. A properly fitted-out and furnished operating room should be provided, which could also serve as an examining room as well. The room should be large enough so as not to be uncomfortably crowded with the furniture and 41 42 EXAMINING BOOM. paraphernalia necessary, and yet small enough to be com- pact. The floor should be of tile or granolithic material so as to be water tight and easily cleansed. The walls should be tiled, enameled, or treated with some material that will stand scrubbing. All corners should be rounded off and as little woodwork as possible should enter into its construction. The location of the suite will depend largely upon the location of the building itself, but where there is a choice, it will depend upon whether the strongest light is desired in the forenoon or afternoon. Heavy shades should be provided so that the room may be darkened when arti- ficial light is to be used. The walls and everything in the room, as far as possible, should be white. White al- ways gives the patient an impression of cleanliness at once; and the slightest soiling is so conspicuous that they must be kept clean. The furniture necessary consists of a surgical table, or chair, which can be adjusted to various positions ; an aseptic glass and metal instrument case, glass top instru- ment table, revolving stool, sterilizer stand, foot tub ; with enameled bowls and dressing basins, pail, com- pressed air tank, and plumbing, electric light wiring, and other fixtures according to the ideas of the individual. If it is not possible to have a toilet room adjoining the operating room, a commode should be added to the equipment. A retiring or recovery room is almost a necessity as well. The author prefers an examining table to a surgical chair. He believes that it is not more distasteful to the patient to get up on a table to be examined, than it is to be seated in a chair and by the turn of a crank, to be EXAMINING TABLE. 43 Fig. 5. Columbus Operating Table. This is a light but strong all metal operating table, particularly adapted for office work. It may be thrown into any position that either surgical chair or table can be. jerked or jarred, or flopped into position. Surgical chairs are cumbersome and always getting out of order, and are not to be compared with a nice, clean operating table of white enameled iron which can be adjusted to any 44 OFFICE EQUIPMENT. position required. Hair-stuffed cushions covered with white rubber and not exceeding one inch in thickness are placed on top of the table. The cushions should be thick enough so as to counteract the hardness of the table, and yet not so thick that the patient's buttocks sink down into them. Fig. 6. A Simple Form of Instrument Sterilizer for Office Use. Plenty of clean white sheets should be always on hand and the examiner will find it more comfortable and clean- ly to wear a white cotton coat such as are commonly worn Fig. 7. A Small Instrument and Dressing Sterilizer. This is a very simple and popular form of steam sterilizer. The dres- sings for an office operation may be sterilized in the trays above the boil- ing instruments. OFFICE EQUIPMENT. 45 by dentists. The author has found the electric head light very useful where the interior of the rectum is to be examined, and believes it so far superior to the head mirror and lamp that he no longer uses the latter. "While it is extremely desirable to have such an equip- ment, as has been described above, a very satisfactory examination can be made on any sort of a table or bed Fig. 8. Characteristic Sitting Posture Assumed by Patients Suffering from Ano-Rectal Disease. 46 OBTAINING HISTORY OF RECTAL CASE. with the aid of a good light. The technique which the author uses will be described, not because it will be found the best by all practitioners, but because he has found it the best and most satisfactory in his experience. The patient should first be asked into the consulting room, and in order to put him at his ease, he should be allowed to tell the story of his ailments in his own way. As he mentions symptoms or salient points which are pertinent, they should be noted down for use in Fig. 9. The Quadrants of the Anus. 1. Right anterio-lateral quadrant. 2. Left anterio-lateral quadrant. 3. Right posterio-lateral quadrant. 4. Left posterio-lateral quadrant. PREPARATION FOR EXAMINATION. 47 questioning him later. When he has finished, he should be questioned in a more systematic manner, and his his- tory noted on a special blank or card kept for the pur- HIBTONY Or CASC No Fig. 10. A Simple Form of Record Card Used by the Author. Actual size, four by six inches. pose. The various symptoms brought out in this way, will often suggest a tentative diagnosis, but as has been stated in the preceding chapter, nothing should be taken for granted and a complete rectal examination insisted upon. The patient is then taken into the examining room and prepared for the examination. All clothing, corsets, tight waist bands, or anything which constricts, or has a tendency to interfere with respiration, or to crowd the abdominal organs, or intestines out of place, should be loosened or removed. The patient is then placed on the 48 DIGITAL EXAMINATION. table in the left lateral or Sims' position and covered with sheets in such a manner that there is never any un- necessary exposure. In Account WIT DR. LOUIS J. H'KSCHMAN DETROIT _ ADDRESS. 0I*H ie 1 2345-678 9 10 11 12 iVlY 15 BEhDERED CMAftGtS 6 if 18 19 21 21 24 25 K 33 28 29 X 31 DATE Fig. 11. Reverse Side of the Preceding on Which the Account with the Patient Can Be Kept. Size, four by six inches. With the patient so placed as to get good day light, or by the aid of the head light, the anus, perineum, buttocks, and the genital organs are carefully examined. Discolor- ations, protrusions, elevations, swellings, abrasions, cracks, skin eruptions, crusts, scars, discharge, or any other abnormal appearances of the parts should be care- fully noted. With the patient in the same position, digital examina- tion is next in order. It is well to have in readiness a bowl of some antiseptic solution, preferably one which will not attack steel instruments. The author has found a 1-10,000 solution of mercuric iodide the most satisfac- EXTERNAL INSPECTION. Fig. 12. External Inspection. This drawing well illustrates the posture of both examiner and patient, and shows the extent to which the anus may be dilated by traction of the skin of the buttocks. Fig. 13. Electric Magnifying Headlight. This is a very simple, inexpensive, and very satisfactory electric head- light. It may be used either on the street current or dry cell battery. It is very light, compact, and can be so adjusted that the light is brought between the operator's eyes. There is a condensing lens blown onto the front of the lamp greatly increasing its efficiency. 50 LUBRICANTS FOR DIGITAL EXAMINATION. tory. Its germicidal power is equal to that of the bi- chloride in the strength of 1-2,000. Finger cots should always be at hand. The examining finger protected by the finger cot should always be well lubricated before an examination is attempted. There are a number of excellent commercial lubricants on the market, such as Hartz's "Lubra-Septol" and Van Horn's Fig. 14. Method of Applying Lubricant From Collapsible Tube to Examining Finger Protected With a Rubber Finger Cot. " K-Y," but sterile vaseline or oil will be found to answer the purpose equally as well. The author uses a lubri- cant which has given him perfect satisfaction. It is pre- pared as follows: ^ Oxy-cyanide of Mercury 0.246 Glycerine 20. Tragacanth 3. Water 100. Dispense in two ounce collapsible lead tubes. POSTURES FOE DIGITAL EXAMINATION. 51 The posture of the patient for digital examination is very important. The old method of having a patient simply bend or lean over a chair or table, then inserting the index finger, is not nearly so satisfactory, comfort- able, or thorough to either examiner or patient, as the lateral or Sims' position. The patient in the Sims' posi- tion is relaxed and at ease, and the parts presented in such a manner as to give the clearest view and produce most satisfactory results. Fig. 15. Incorrect Method of Digital Examination. This method was formerly deemed the only proper method of making a digital examination of the anus and rectum. Contrast this with the following illustration. The wearing of a thin rubber finger cot is done for several reasons. In the first place, it protects the wearer from infection. It also prevents the soiling of the finger with fecal material, pus, or discharge with their dis- 52 POSTURES FOR DIGITAL EXAMINATION. agreeable odors. It does not interfere with the sense of touch, which can be educated to extreme delicacy even with the cot. From the patient's standpoint it is much more desirable the smooth rubber covering over the finger enabling it to enter much more easily than the un- protected finger, and there is no danger of irritating sensitive areas with the finger nail. If one wishes to make a digital examination, and a finger cot is not avail- able, the nail of the examining finger should be trimmed close and the crevices under and around it filled by scratching the surface of a bar of soap. The rest of the Fig. 16. Correct Method of Digital Examination. With the patient in the lateral or Sims position, the examiner standing josite the sacral region of the patient, digital exploration of the anus cl rectum can be accomplished with much more thoroughness, satisfac- tion and comfort to both. DIGITAL EXAMINATION. 53 finger nail should be covered with soap suds, vaseline, or whatever lubricant is handy. After the examination, the lubricating material should be wiped from the finger with a dry cloth or absorbent cotton before washing the hands. The position of the patient and the examiner as well is .shown in the accompanying illustration. The protected and lubricated finger which is usually the index finger of the right hand, is pressed against the anus with its flexor .surface toward the posterior commissure, and the patient is asked to bear down. The finger is first entered point- ing anteriorly until the sphincters have been passed, and ihen passed backward and upward in the posterior direc- tion. As the finger enters, it should be gently turned from side to side sweeping over all the surfaces of the anal canal and lower rectum. Any change from the nor- mal, soft, velvety feeling of this region such as elevations, depressions, or indurations should be carefully noted. The location of the feces is also important, particularly where symptoms of interference with normal defecation are presented. It is therefore important not to give an enema before the first digital examination. Unless one wishes to determine conditions high up in the rectum, or to make a recto-abdominal examination, one should not feel too high in searching for the source of painful rec- tal symptoms. Most of these diseased conditions will be found within the first two inches from the anal outlet. Often in inserting the finger, the various lesions are pushed up into the rectum giving the impression that they are higher than they actually are. It is with the withdrawal of the finger therefore that more valuable information is often obtained than on its introduction. Where the sphincters are so sensitive or tightly con- 54 VAGINO-KECTAL EXAMINATION. tracted as to prevent digital examination being accom- plished without great pain to the patient, dilatation of the sphincters by means of local anesthesia should be re- sorted to The technique of local anesthesia is fully de- scribed in Chapter XV, to which the reader is referred. Fig. 17. Vaginal Eversion of the Anus. This method is useful in examining the anterior wall of the anus, and lower rectum in female patients; particularly those who have borne children and who have lax perineums. In women much valuable information can be gained oftentimes by vagino-rectal examination which is ac- complished either by the index finger in the rectum and the thumb in the vagina ; or by using the index finger of the left hand in the vagina while the right is in the rec- tum. Often in women where the perineum is lax, the anus may be everted by downward and outward pressure of VAGIXAL EVERSIOX LITHOTOMY POSITION. 55 the index finger of the right hand in the vagina, while the anus is spread between the index finger and thumb of the left hand. Fig. 18. Another Method of Everting the Anal Tissues for Inspection. From Crossen's Diagnosis and Treatment of Diseases of Women. The lithotomy position, while in most cases not nearly so satisfactory for complete ocular inspection of the ex- ternal parts or the use of the anoscope nor as comfort- able for the patient has its place in the examination of the patient suffering from ano-rectal diseases. If for some reason or other the patient is not comfortable in the lateral position, which will occasionally be the case in those who suffer from rheumatism or some other joint 56 THE LITHOTOMY POSITION. affection; or on account of an unusual amount of adipose tissue the patient's buttocks cannot be well separated in Fig. 19. Indicating the Amount of Possible Eversion of Anal Tissues When the Pelvic Floor is Lax as in Multiparae. Dudley : Practice of Gynecology. the lateral position, the lithotomy position will be found much more satisfactory. The patient is asked to lie flat upon the table after the clothing has been removed, and a sheet thrown over him. The knees are flexed upon the thighs and the thighs upon the abdomen and the patient's buttocks pulled well down to the edge of the table. The legs are kept in this position either by an assistant or by the use of a Kelly leg holder or Clover's crutch, or by the stirrups or leg holders which accompany the surgical THE LITHOTOMY POSITION. 57 table used by the author, known as the Columbus table. In this position the perineal space and the peri-anal re- Fig. 20. Posture and Method of Making Recto-Abdominal Bimanual Examination. Fig. 21. Method cf Recto- Abdominal Palpation. The Position of Both Hands in Relation to the Uterus and Vagina is well shown. Montgomery: Practical Gynecology. 58 BI-MANUAL EXAMINATION. gion can be inspected and palpated, and in the case of a female patient, examination of the genital organs carried out at the same time. In this position also the condition of the prostate and seminal vesicles of the male can be made out, and oftentimes the extent and direction of a fistulous tract determined more satisfactorily than in the lateral position. The condition of the coccyx can be de- termined with the patient in the lithotomy position by inserting one finger into the rectum and the other hand over the region of the coccyx, or by the insertion of the forefinger into the rectum and the thumb of the same hand over the location of the coccyx on the outside. Fig. 22. Palpation of Rectum Through Posterior Vaginal Wall. Ashton : Practice of Gynecology. With the patient in the lithotomy position, bi-manual abdomino-vaginal, and abdomino-rectal examination are accomplished. It is a good, safe plan to include both of these methods in the routine examination of every patient because very frequently unsuspected or beginning dis- ABDOMINO-BECTAL, PALPATION. 59 eased conditions in the pelvis and abdomen are discovered before they have given rise to subjective symptoms. In any case presenting the symptom of sacral backache, Fig. 23. Method of Examining the Coccyx With One Hand. This may also be done with one hand over the region of the coccyx posterior to and above the anus, and the index finger of the -other inside of the rectum. Hirst : Diseases of Women. weight in the pelvis, the passage of blood or pus with the stool, or diarrhoea abdomino-rectal palpation, with the right index finger inserted as high as possible in the rec- tum, and the left hand over the right and left iliac fossae and above the pubes is imperative. The squatting position, or the position assumed by the aboriginal races in defecation, is oftentimes of great value in the diagnosis of those conditions made manifest by protrusions from the anal orifice. The patient is asked to 60 THE SQUATTING POSITION. remove his clothing and to squat as if he wished to de- fecate. It is best to place a shallow basin or receptacle Fig. 24. Ischio-Rectal Abscess. This illustration drawn from a photograph of one of the author's cases, besides showing the point of swelling and fluctuation of the abscess, illustrates the method of bimanual palpation in the examination and diagnosis of the condition. At the posterior commissure of the anus will be seen a small external hemorrhoid as well. underneath him lest, during his straining efforts, feces, pus, blood or discharge may escape. The patient is then asked to bear down or strain ; when in this position, pro- lapsing internal hemorrhoids, polypi, or prolapse of the THE SQUATTING POSITION. 61 rectum or anus, will be brought into view in a very satis- factory manner. Fig. 25. Squatting Position. This position shows the natural posture for defecation, and is useful in extruding prolapsing conditions. Drawn from a photograph. Before proceeding to internal inspection, the rectum should be emptied by means of an enema of soap suds and water. If one's office equipment does not include an irrigator, a two quart fountain syringe will answer very nicely. Another very simple method is to use a three or 62 INTEENAL INSPECTION. four ounce soft tipped, all-rubber bulb syringe, known as the ear and ulcer syringe. With the patient in the lateral or Sims' position, a pint or more of solution can be gently injected and the rectum cleansed in a very satisfactory manner the patient being allowed to rise and go to the toilet to expell it. Fig. 26. Three Ounce All Rubber Bulb Syringe. Useful in irrigating and in giving enemas when ordinary irrigator is not available. Fig. 27. Posture and Method of Using the Author's Fenestrated Anoscope, for Examining the Anal Canal. KNEE-SHOULDER POSITION. 63 Internal inspection of the anus, rectum, and sigmoid is best accomplished with the patient in the knee-shoulder position. The patient who has been lying in the Sims' position^ is asked to kneel on the table and to maintain the kneeling position while the examiner brings the left shoulder down to the table flush with the knees. The pa- tient should not be allowed to rest on the elbows as the trunk must present enough of an inclined plane to allow atmospheric dilatation of the rectum, when the examin- ing instruments are inserted, and allow the other abdom- inal organs to fall away from the rectum. The accom- panying illustrations clearly show the difference between the correct and incorrect postures. Fig. 28. Knee-Elbow Position. This position is often mistakenly employed in proctoscopy, and should not be confused with the knee-shoulder position, as depicted in the fol- lowing illustration. INTERNAL INSPECTION. Oftentimes the internal opening of a fistula can be de- termined by the injection through its external opening of a solution of 25 per cent peroxide of hydrogen. Upon examining through the proctoscope, while injecting, the internal opening can be easily located by the appearance of the bubbling peroxide solution. Solutions of methy- lene blue or milk of magnesia or bismuth can also be used in like manner for a similar purpose. Fig. 29. Knee-Shoulder Position. This is the correct posture for proctoscopic examination. By com- paring this with the preceding one, it will be seen that in the knee- shoulder position much more of an inclined plane is produced. Note the direction in which the proctoscope is entered. For internal inspection of the anal canal, the lateral Sims' position is sufficient. Instruments The instruments required for inspec- tion of the anal canal or anoscopy are: a cylindrical ano- INSTRUMENTS FOE ANO3COPY. 65 scope whose internal opening is cut on the slant and con- taining an obturator tapering to a blunt round extremity (see figure 30) ; the tapering, adjustable fenestrated anoscope with closed extremity (see figure 31); a fine probe (see figure 3:2), made of pure silver, and a pair of dressing forceps (see figure 33). An ordinary Kelly ano- scope (see figure 34) is also oftentimes very useful. Fig. 30. Author's Anoscope With Oblique Opening and Slanting Obturator. Bearing in mind from the digital examination, the location of the lesions in the anal canal, the fenestrated anoscope well lubricated with the opening turned so as to be opposite the lesion when entered, is pressed against the anus and gently inserted while the patient is bearing down against it. If an opening is detected, this may be explored with the soft silver probe, which may be bent easily at any angle, care being taken to use no force and to handle it with extreme gentleness and delicacy. In some cases, the instrument with the opening on the slant 66 TECHNIQUE OF ANOSCOPY. is used in preference, its opening giving nearly twice the field of the ordinary round opening of the Kelly instru- Fig. 31. Author's Fenestrated Adjustable Anoscope. This instrument is provided with a closed extremity; has a fenestrum \Y% in. long by ]/2 in. wide; can be revolved so that the fenestrum can be placed at any angle in relation to the handle, and on account of the peculiar shape of the ferrule at the proximal end of the fenestrum, is self-retaining. ment. The Kelly anoscope, however, is useful in expos- ing conditions which prolapse the patient being asked Fig. 32. Silver Probe. This type of probe, equipped with a proper handle and made of pure annealed silver, is the best for use in rectal examination. It is made in many sizes. to strain and bear down while the instrument is being withdrawn. By so doing, prolapsing hemorrhoids, prolapsus-ani, or recti, polypi, or papillae are brought out into view. If the view is obscured, at any time, a bit of cotton should be taken up with the dressing forceps to cleanse the parts. PROCTOSCOPY. 67 The knee-shoulder position is by far the most satisfac- tory in the author's experience for examination of the Fig. 33. Long Alligator Forceps. These are made in different sizes raiging from 9 to 14 inches in length and are very useful in proctoscopic and sigmoidoscopic examination. rectal cavity and most of the sigmoid. Not only does the atmospheric pressure balloon out the rectum, to its Fig. 34. Kelly Anoscope. Useful in prolapsing conditions. fullest capacity, but this position also removes the pres- sure of other abdominal organs from the rectum by al- lowing them to fall away. 68 PKOCTOSCOPY WITHOUT INSTKUMENTS. The only instruments required for proctoscopy or ocu- lar inspection of the rectal cavity are, a cylindrical proc- toscope, from four to six inches in length and from three- quarters to seven-eighths of an inch in diameter, and a Fig. 35. Bivalve Rectal Speculum. This is an instrument formerly used for rectal examinations but which, in the author's opinion, has absolutely no place in modern methods of examination. It should be used in operative work, arid only when the patient is under general anesthesia. pair of long alligator forceps. In an emergency, a very fair inspection of the rectal cavity may be had without any instruments whatever. The technique of proctoscopy without instruments, is as follows: With the patient in the knee-shoulder position, the index finger of the right hand, protected by a finger cot, and well lubricated, is gently inserted and the sphincter massaged; then the index finger of the left hand, similarly protected and lub- ricated, is introduced back to back with the finger in the rectum. The introduction of the second finger should. be done slowly and gently and with a massage motion. When it has been introduced to an equal depth with its fellow, that is, up to the second joint of the finger, the TECHNIQUE OP PEOCTOSCOPY. 69 fingers should be gently separated. The atmospheric air then rushes in with an audible hiss, and the rectum bal- loons out so that it can be examined with the aid of the electric headlight or reflected light from the head mirror. Fig. 36. Wales Rectal Bougie. This is made of flexible rubber and provided with a canal through which irrigation may be given and which allows the entrance of at- mospheric air and escape of gas during its introduction. There are twelve different sizes. With this method, however, one cannot see behind the rectal valves or folds of Houston, and it is only of value where a suitable examining instrument is not at hand and the lowermost portion of the rectal cavity only is to be explored. The technique of proctoscopy is as follows: With a proctoscope whose outside diameter does not exceed the diameter of the operator's index finger, all parts of the rectal cavity can be successfully explored, and its intro- duction causes no more pain or discomfort than digital examination. The instrument used by the author is a modification of that devised by T. C. Martin. It is five and one-half inches long from the edge of the flange to 70 TECHNIQUE OF PROCTOSCOPY. the tip of the obturator. Its outside diameter is three- quarters of an inch. It is provided with an obturator made of metal, with a conical extremity which fits it very snugly. The obturator is channeled so as to allow the ingress of air during its introduction. With the pa- tient in the knee-shoulder position, the well lubricated proctoscope is pressed against the anus, pointing in Fig. 37. Author's Modification of the Martin Proctoscope. Provided with a metal obturator with conical extremity, which con- tains an air vent running through its entire length. It is ^ of an inch in diameter and six inches long. the direction of the patient's umbilicus, and the patient asked to bear down, as in the act of defecation. While he is doing so, the proctoscope is inserted gently, first downward and forward, until the anal canal has been passed; when it is tilted upward and backward and the rectal cavity is entered without difficulty. By asking the patient to bear down during the introduction of the instrument, the patient forces his anus down over the proctoscope, as it were, and introduction is accomplished TECHNIQUE OF PROCTOSCOPY. 71 with much ease. Holding- the proctoscope in the left hand, the obturator is withdrawn with the right. Inspec- tion of the entire rectal cavity can then be accomplished with as much ease and completeness as the examination of the nose or throat. The proctoscope should always be entered to its fullest length before the obturator is withdrawn. After having examined the uppermost part of the rectum, noting the appearance and condition of the recto- sigmoidal juncture, it is slowly withdrawn, the examin- er in the meanwhile noting the condition of the lining membrane of the rectum, the rectal valves, and anal canal until the instrument is completely withdrawn. If, upon the withdrawal of the obturator the opening of the proc- toscope seems closed by a wall of rectal mucous mem- brane, by manipulating the instrument so that its inner extremity is moved to one side or the other, the obstruc- tion will often be found to be one of the rectal valves, or folds of Houston; and on pushing this to one side with the instrument, a new field is exposed to view. With the proctoscope in position, the size, density and thickness of the rectal valves can be noted by means of a probe or ap- plicator bent at a right angle; ulcerations of the rectal wall, their extent and severity noted; the condition of the circulation of the rectum ; the presence of polypi in fact, any deviation from the normal smooth pinkish red appearance of the mucous membrane of the normal rec- tum easily made out by this method of examination. While the proctoscope is in position, local applications to diseased areas, sprays, insufflations and other thera- peutic measures, when indicated, may be carried on under the direct guidance of the eye. The alligator for- 72 EXAGGERATED LITHOTOMY POSITION. ceps are useful for swabbing out the rectum and obtain- ing tissue for microscopical examination. The exaggerated lithotomy position also sometimes known as the genito-urinary position, is very useful when it is necessary to examine the sigmoid flexure. This position is secured by putting the patient into the litho- omy position as above described, and then slowly lower- Fig. 38. Exaggerated Lithotomy Position. . Illustrating posture of the patient and technique of the introduction of the sigmoidoscope. ing the head of the table so as to leave the buttocks somewhat higher than the patient's shoulders. This puts the patient into a sort of semi-Trendelenburg position with the thighs and knees flexed. In this position it will be found comparatively easy to introduce the sigmoido- TECHNIQUE OF SIGMOIDOSCOPY. 73 scope and secure atmospheric dilatation of the sigmoid flexure. The instruments necessary for the ocular inspection of the sigmoid flexure or sigmoidoscopy, are sigmoido- scopes varying in length from nine to fourteen inches, and from three-quarters to an inch in circumference, and Fig. 39. Kelly Sigmoidoscope. This is made hi sizes varying from eight to fourteen inches in length. the long alligator forceps. The instrument devised by Kelly is very serviceable, but its introduction has been Fig. 40. Sigmoidoscope Provided With the Author's Tilting Obturator. The tilting obturator is of value in the insertion of the Sigmoidoscope, allowing it to round the sacral curve with greater facility. 74 ATEESIA ANI VAGINALIS. made much easier by the use of an obturator whose pro- jecting extremity tilts so as to allow of easier introduc- tion in rounding the curve of the sacrum. Tuttle has devised such an instrument as has also the author. The only other instrument required is a long alligator for- Fig. 41. Atresia Ani Vaginalis (Complete.) Photograph of author's case. This illustrates a case of complete absence of the anus with the rectum emptying itself through the vagina. This patient was 25 years old and did not know until shortly before consulting the author, that she was different from other people. She had partial control of her fecal movements by an over-development of her sphincter-vaginae. At the normal location of the anus was found a rudimentary external sphincter. The case was operated upon by the author, the vaginal opening closed and the rectum brought down to the normal anal site, with the result that the patient has an apparently nor- mal anus with good control. The above photograph well shows the septum separating the rectal opening of the vagina from the upper vaginal canal. ATRESIA ANI VAGINALJS. 75 ceps for use in swabbing out the sigmoid cavity and for the purpose of removing tissue for microscopical exam- ination. Sigmoidoscopy may be accomplished with the patient in the knee-shoulder position, but much more satisfactory results are obtained from the employment of the exaggerated lithotomy position. Fig. 42. Atresia Ani Vaginalis (Incomplete.) This photograph, taken from one of the author's cases, seen in con- sultation, differs from the preceding in that while the patient passed her stools through the vaginal opening, the anus was not entirely occluded, there being a small ano-vaginal fistula. This patient was 23 years of age and had a remarkably well developed sphincter vaginae and was able to well control her fecal movements through the vulvar orifice. This case was likewise operated and the rectum restored to its normal position with a good functional and cosmetic result. The external sphincter muscle was more fully developed in this case than in the preceding one, and control followed much more rapidly. 76 CONGENITAL MALFORMATIONS. Before leaving the subject of examination of the pa- tient, the author would advise his readers to carefully examine every patient to make sure that there is not present some congenital defect or malformation of the anus or rectum. Every infant at birth should be examined by the attending obstetrician to make sure that the ano-rectal canal is patent, as imperforate anus, while said to occur but once in 10,000 cases, seems to the author, in his own experience and that of his profes- sional friends with whom he has consulted, to have oc- curred apparently more frequently. If imperforate anus is not recognized, the child will either die in a few hours or days if the condition is not remedied, and even then the operation is attended with a very high mortality; or nature will occasionally form a new outlet for the escape of the feces. In girls this happens more frequent- ly through the vagina and in male infants through the scrotum, bladder or urethra. Two cases have come under the author's notice (See Figs. 41 and 42), in which young women were allowed to grow to the ages of 23 and 25 respectively with congenital defects so serious as to pre- clude the possibility of marriage until remedied. In one (Fig. 41) there was a complete absence of an anal ori- fice, and in the other (Fig. 42), an aperture about one- fifth of the normal size. In both cases, defecation took place through the false opening into the vagina. CHAPTER IV. CONSTIPATION AND OBSTIPATION. Constipation may be defined as the voiding of insuf- ficient amounts or the abnormally prolonged retention of fecal material in the intestinal canal. Constipation in contradistinction to obstipation, is due to purely func- tional diseases or conditions of some portion of the intes- tinal tract. Obstipation, on the other hand, is a condition in which there is a sufficient quantity of fecal material, and a normal functional activity; but in which some de- formity, growth, flexion, constricture, or foreign body in the intestinal canal offers a mechanical obstruction to the passage of the fecal current. These two conditions are so frequently confounded in the mind of the average prac- titioner that the distinction must be always born in mind ; for the treatment of these conditions, while they may present similar symptoms, is entirely different. Constipation is really but a relative condition. One individual may have two or three passages daily and still be constipated, while another individual may have but one passage a week and not be constipated. Constipation in itself is not a disease but merely a symptom of a great many diseased conditions, but is so often the only apparent symptom 'of which the patient complains, that its discussion as a separate disease entity is deemed advisable. 78 PHYSIOLOGY OF DEFECATION. Obstipation is caused by such mechanical conditions as malformations of the intestinal canal, stricture, ad- hesions, pressure from the pregnant uterus and the va- rious abdominal tumors, angulation, enteroptosis, steno- sis of the ileo-cecal valve, fecal impaction, foreign bodies, hypertrophied rectal valves, prolapsus, large hemor- rhoids, enlarged prostate and hypertrophied sphincters. Chronic constipation is a condition which affects a large proportion of all the patients treated by every prac- titioner of medicine. * It is a condition which is brought about by our modern, so-called "strenuous life." We find it in the infant and in the nonagenarian. It is due to a great many factors, and in order that one may under- stand it more fully, I will review some points in the physiology of peristalsis and defecation. Physiology of Defecation. Up to the last moment at which the fecal mass is expelled from the anus, the in- gested materials are carried through the intestinal tract by what is known as peristaltic action. After the food has entered the stomach and the albuminoids converted into peptones, it passes through the pylorus into the small intestine. As the stomach contents pass through the pylorus, they are acid. The secretions in the small bowel the bile and the pancreatic juice, being alkaline ; when the acid stomach contents are poured into the small intestine, coming in contact with the alkaline intestinal secretions, a stimulation, or irritation is caused, which produces a wave of muscular contraction, or peristalsis. At the same time that the chemical reaction of the acid stomach contents upon the alkaline contents of the intes- tine is going on, certain gases are created. These gases are not abnormal but serve a most useful purpose. It is PHYSIOLOGY OF DEFECATION. 79 when they are in too great quantities and too severe peris- talsis and consequent too great distension of the intestinal canal ensue; that they are harmful. They then cause atony or paralysis of the circular muscle fibres and loss of tone. These gases are largely reabsorbed by the blood vessels or discharged with the feces. If these gases in their downward passage meet any obstruction, they are forced backward into the stomach and are discharged in this direction. Another important source of stimulation to the coats of the bowel is the harsh, indigestible particles of food which are not acted upon by the digestive secretions. These also irritate, and stimulate the contraction of the circular muscular fibres in the small intestine. Of no small importance is the stimulus caused by the to and fro movement imparted to the bowel by the action of respira- tion. The excursions of the diaphragm upward and downward impart to the small bowel in particular, and also to the transverse colon, a movement which stirs up and churns, as it were, the intestinal contents. It changes the position of the bowel and helps to keep the intestinal contents on the move. It can be easily seen how anything which constricts and prevents the full expansion of the chest will interfere with the intestinal functions and assist in causing constipation. The intestinal contents are fluid until they reach the ileo-cecal valve. In the cecurn they become less fluid and, having to travel against the force of gravity, their move- ment in the large bowel is checked. Staying, as they do, in this portion of the bowel for some time, the fluid con- stituents are gradually absorbed, and the nearer to the sigmoid the feces, the more solid they become. The mucous 80 ETIOLOGY. membrane of the colon is thicker and not so sensitive as that of the small bowel and requires more stimulation, consequently the stools are more solid in this portion of the bowel. If however, too much vegetable fibre and in- digestible material is present, the colon tends to become over-stimulated, over-distended, and atonic; the fecal mass moves very slowly and chronic constipation, and sometimes fecal impaction results. The fecal material when it reaches the siginoid, rests until ready to be passed out through the rectum and anus, as a fecal move- ment. Causes. It can readily be seen that anything which interferes with the proper development and exercise of the intestinal muscle layers will interfere with the proper movement of the intestinal contents and with expulsion at the proper time. In the first place, enough fluid must be taken into the system daily to keep the intestinal con- tents in solution and to properly supply the various or- gans of the body. People who do not drink enough water suffer from constipation because of the re-absorp- tion of fluids from the intestinal tract and consequent hard and dry stools. People who drink great quantities of water with their meals drown their stomach contents ; undigested particles of food are sent through the pylorus with gushes of greatly diluted gastric juice; the feeble acid reaction of this mixture does not cause the proper reaction with the alkaline intestinal contents ; the proper amount of gases is not evolved and quantities of irritat- ing food particles are passed down the small bowel. This is another cause of loss of tone. It is a well known fact that carnivorous animals are constipated while the herbivorous animals have full and ETIOLOGY. 81 frequent bowel movements. It therefore behooves us to see that a sufficient quantity of vegetable material which will leave undigested fibre in sufficient and not too great quantities, such as corn, celery, beet tops, let- tuce, spinach, water cress, endive, kale, and other greens, is incorporated into our daily regimen. It should also contain a sufficient quantity of mineral salts, which are natural laxatives. It should contain sweets within rea- sonable limits, because of the gas development which goes with them, and the fact that carbon dioxide gas is one of our best laxatives should not be forgotten. Above all, the food of the individual must not be concentrated; it must give sufficient bulk to the stool so that it will properly fill and distend the gut, give it work to do and produce the proper mechanical stimulus to cause contraction. The value of whole wheat bread and bran lies in the quantity of cellulose in the husk, which is a very important element. People who eat too fast do not properly masticate their food, causing improper di- gestion with improper bowel contents, and have improper stimuli to peristalsis and consequently improper stools. Outside of dietetic error, the most important cause of constipation is neglect. The school child hears the call of nature, the fecal mass is ready to be extruded, he is receiving powerful stimuli for the dilatation of the sphincters and the expulsion of his bowel contents; but in our modern schools, the lesson hour is more import- ant than the functions of nature! The child is not al- lowed to go and relieve himself. He restrains nature's efforts ; the desire passes away. The continuance of this performance day after day soon makes the child a chron- ically constipated child. 82 ETIOLOGY. While peristalsis is involuntary, in the vast majority of people the voluntary control over the sphincter is normally sufficient to withstand it. The strong expul- sive efforts soon weaken when retarded by a tightly contracted sphincter, and shortly the constipated habit is induced. The young girl in society is taken with a desire to move her bowels and either because the time is not convenient and she restrains nature's efforts, the de- sire soon passes away and she is constipated ; or she may be willing to satisfy nature's desire, but in order to reach the toilet room she must perhaps pass through a crowded room, and false modesty prevents her from allowing her friends to see her go in the direction of the toilet room. A very important provision in architecture of homes and institutions should be the placing of the toilet room in such an inconspicuous place that a person may reach the same without being subjected to the gaze of others. The business man, the traveller, the physician, the school teacher, the professional man all refuse to obey nature's call because the time is not convenient, and thus because we have not time to move our bowels when they want to be moved, we have become a constipated nation ! I think this neglect and indifference is the most impor- tant cause of constipation. Another contributing cause to the voluntary repres- sion of defecation is the fact that in institutions, and in large buildings, there are not enough toilet rooms for the number of inmates. Where one has to wait long for his turn, the desire is soon lost. The shape of the toilet seat and its height from the floor are all of importance in the production of a good stool. The seat should be so made that the person using DIAGNOSIS AND TREATMENT. 83 it is in the squatting position with the buttocks well separated so as to allow the free excursion upward and downward of the muscles, which go to form the pel- vic floor, and the full action of all the other muscles in- volved in defecation brought into play. People leading sedentary lives, who do not get sufficient exercise, of course, are constipated, for exercise is one of the im- portant factors in keeping all bodily functions normal. There are many other causes which may contribute to the production of constipation in individual cases, but those mentioned are the most important, and the most common. Diagnosis and Treatment. When the bowel has be- come atonic, remedies to restore its tone must be em- ployed. In the treatment of acute constipation, cathartic drugs, suppositories, enemata, all have their proper place; but the victim of chronic constipation should no more be made a drug fiend than the victim of chronic appendicitis. Instead of causing irritating, irregular erratic and violent peristaltic movements at certain times during the day; and instead of changing from one ca- thartic to another and increasing the dosage instead of taking away the work of the bowel by flushing with enemata we should strive to bring that bowel back to its normal tone by imitating nature's methods. The only place for a cathartic in the treatment of chronic consti- pation is at the beginning of the treatment. When a patient consults you, complaining of infre- quent or insufficient bowel movements, the first thing to do is to make a diagnosis between constipation and ob- stipation. The patient should be examined carefully, his abdomen should be palpated thoroughly; the female pa- 84 TREATMENT. tient should have a bimaimal examination ; the male pa- tient should have the genito-urinary organs examined, as many cases of constipation are reflexes from bladder and prostatic conditions. The rectum and sigmoid should be thoroughly explored and a complete proctoscopic ex- amination with the patient in the knee-shoulder position is imperative in every patient complaining of impeded fecal movements. After you have satisfied yourself that you have a case of constipation, and not obstipation, to deal with, and after carefully questioning your patient as to habits, diet and previous history; the question of treatment presents itself. Dietetic errors should be corrected and the patient in- structed as to the time and the quantity and the kinds of food to take. If he is not able to properly masticate his food, he should consult his dentist. The teeth should be put into perfect shape. He should be instructed to drink from six to eight glasses of water in every twenty-four hours the first glass on rising, the last glass on retiring. He should drink plenty of water between meals, but very sparingly with meals. He should be instructed to eat a sufficient amount of vegetable foods and not to remove outside coverings of such fruits as pears, apples and peaches, before eating them. He should be instructed to take out-door exercise: to play tennis; to play golf; to go horse-back riding or bicycle riding; to take long walks. He should take breathing exercises, and should develop his abdominal muscles. Any local condition, such as hemorrhoids, which of themselves do not cause constipation but are caused by constipation, but by their presence prevent natural move- ments, should be corrected. Fissures, ulcers, or excoria- TREATMENT. 80 tions of the anus, should be remedied by surgical means or treated locally. Proctitis should be relieved by the proper sprays and medications applied locally. Run down patients should receive in addition, massage from a properly qualified masseur. The abnormally tight sphincter should be dilated or given vibratory massage, and the atonic lower bowel should be properly massaged. A great many drugless methods of treating constipa- tion have been offered to the medical profession. All kinds of electric and external massage, cannon-balls, gymnastics, vibratory massage, and what not, have all been tried, and while satisfactory results have been ob- tained from each of them in certain cases, there still seems something to be desired in the successful treat- ment of chronic constipation. The direct stimulation of the atonic sigmoid and rec- tum by means of mechanical dilatation has. up to the present time, given the best results. Rubber bags, which have been introduced through the proctoscope into the sigmoid and inflated, have been used by Turck and others with excellent results. Tamponing the rectum and sig- moid with cotton, wool, or gauze, as advocated by Mac- Millan, has, by its mechanical irritation of the mucous coats of the bowel and its simulating the normal bowel contents produced satisfactory evacuation. The incon- venience of carrying around a tampon or inflated bag in the rectum or sigmoid for from four to six, or even twelve hours, has, however, militated somewhat against the more general use of these methods. W. Teachnor, of Columbus, 0., has successfully treated a number of cases by simple inflation of the rectum and sigmoid by the en- 86 AUTHOR'S METHOD OF RECTAL MASSAGE. trance of air through the proctoscope, while the patient is in the knee-shoulder position. Author's Method. The author has devised a very sim- ple pneumatic dilator for accomplishing this distention, and has achieved very happy results from its use. No great originality is claimed for this device. It consists simply of a specially devised rubber bag with a stem, which is slipped over the distal end of a Wales bougie Fig. 43. The Author's Pneumatic Rubber Dilating Rectal Massage Bag Equipped With a Hand Bulb. (No. 3-5), the Wales bougie being canaled (Fig. 43) and containing an air vent in the handle which is covered by the finger until the air is to be expelled. Compressed air at a low pressure (one to three pounds) is allowed to slowly enter the bag, and distension to any desired ex- tent is produced. By means of an ordinary cut-off valve this distension can be easily regulated. Where the com- TECHNIQUE OF RECTAL MASSAGE. 87 pressed air apparatus is not convenient, an ordinary atomizer bulb or a small bicycle pump can be utilized. The patient is placed in the Sims position. The bag is lubricated and deflated, is twisted around itself as an umbrella is rolled on its handle, and passed upward into the rectum following the backward curve of the sacrum, then into the sigmoid to any desired height. ! The Wales bougie being firm enough to carry the bag up into the sig- moid, and yet being flexible, does not create any dis- Fig. 44. Author's Rubber Dilating Rectal Massage Bag. a. Bag deflated. b. Showing the amount of inflation necessary in the average case. comfort or do any injury in its passage ; and it obviates the use of the proctoscope in its introduction. When the bag is in position, it is slowly inflated until the patient complains of either fullness or slight crampy pain, or a desire to move the bowels. The air is allowed to escape by removing the finger from the air vent in the handle 88 TECHNIQUE OF RECTAL MASSAGE. of the bougie, and after an interval of five or ten seconds, it is again inflated to the point of tolerance; the cut-off Fig. 45. Position of Patient and Operator for the Author's Method of Rectal Massage. This is the best position for both the patient and operator in treating chronic constipation with the authors dilating rectal massage bag. valve is disengaged and the opening in the bougie is closed with the thumb, and where the hand-bulb is used, the air vent in handle of the bougie is closed with the finger-tip; and then by a to and fro motion, the appar- atus is gently and slowly withdrawn. This method of removing the apparatus is important as it also gently dilates the sphincter muscles. This treatment is repeated daily for from five days to a week, and usually after the first or second treatment the patient will have a small unaided movement. Ca- thartics and enemata are, of course, strictly enjoined. INTEENAL MEDICATION. 89 Each day the patient will report a slightly larger and more satisfactory defecation. When the defecation ap- proaches the normal, treatments are given only on alter- nate days. After three or four days, the interval is lengthened to two days, and then to three; and then to four; when the patient is asked to report in five or six days. If he reports satisfactory evacuations daily, he is allowed to go a week, and then, if a similar report is made, he is discharged as cured, but asked to return for another treatment on the first day on which he does not have a normal stool. If the case is properly diagnosed and instructions as to a regular time for daily evacuations and strict obe- dience to nature's calls are carried out by the patient, as well as the proper dietary being lived up to ; the re- sults from this method of treatment will be very satis- factory, as the experience of several hundred practi- tioners in all parts of the United States and Canada will testify. The only internal medication which has been found nec- essary in the author's experience, has been the admin- istration of extract of nux vomica in one-fourth to one- half grain doses before meals as a tonic to the bowel muscles. Pancreatin in ten grain doses before meals has been found of value in patients who show symp toms of intestinal indigestion. In those cases where starchy food is found difficult of digestion the adminis- tration of Takadiastase in doses of four to ten grains has been found of service. The author has experienced great satisfaction from the administration of white refined pe- troleum oil, also known as liquid albolene. A prepara- 90 OBSTIPATION. tion such as the following is a very satisfactory way of administering it: Oil of wintergreen or peppermint 1 part. Refined white petroleum oil 8 parts. Directions: A teaspoonful before each meal and at bedtime. This oil has no value whatever as a cathartic and is not acted upon by any oi the digestive secretions. It passes through the stomach and bowel and is expelled unchanged. It acts as a mechanical lubricant to the stool and softens hard masses which have been formed and prevents the formation of others. Other diseases occurring coincidently with consti- pation have to be treated according to their special in- dications and needs. Obstipation. Obstipation as defined at the beginning of the chapter is a purely mechanical condition, there being some pathological condition which narrows, con- stricts, kinks, or obstructs the bowel in such a manner as to offer more resistance than normal peristalsis can over- come. Pressure from various abdominal organs, obstruc- tion from intra-abdominal adhesions, torsion, or angu- lation of the bowel are conditions which can be remedied only by operative interference under general anesthesia and do not come within the scope of this work. Obstipa- tion, however, which is due to hypertrophy of the rectal valves or valves of Houston, fecal impaction, or hypertro- phied sphincters are all amenable to office treatment un- der local anesthesia. THE RECTAL VALVES. 91 The Rectal Valves. While for several years a great controversy has been raised as to whether the rectal valves of Houston are really valves, or simply constant folds of mucous membrane, nevertheless, the fact that hypertrophy of these structures does obstruct and im- pede the flow of the fecal current is now generally admit- ted. The number of cases reported of obstipation which have been relieved only after section of hypertrophied rectal valves, is now so large that the operation of rectal valvotomy has come to be a recognized form of treatment. Anatomical studies of the valves in situ and sections of the valve studied microscopically have shown conclu- sively that they possess all the elements of a typical valve. They are not simple folds of mucous membrane, but are composed of first, mucous membrane; second, a fibrous tissue layer; third, a circular muscular layer; fourth, a longitudinal muscular layer; and, fifth, a sub- serous layer consisting of areolar tissue and fat and con- taining arteries, veins, nerves, and lymphatics. Under certain conditions these rectal valves become thickened and stiffened by the increased deposition of fibrous tis- sue ; in fact, become almost leathery in consistency They may or may not encroach upon the lumen of the bowel. They may not become increased in thickness whatever, but may be simply increased in area so that they occupy from one-half to three-quarters or more of the rectal lu- men. Sometimes one valve may be enlarged and some- times two or three. This form of enlargement presents a firm and unyielding barrier to the normal descent of the feces. Patients -with so-called constipation who have run the whole gamut of cathartics, enemas, massage, dietetics, 92 RECTAL VALVOTOMY. electricity, osteopathy and Christian " Science" have not been relieved until they have had a proper proctologic examination and the enlarged rectal valves which were discovered, operated upon. The author has had repeat- edly such cases referred to him and the operation of valvotomy has relieved a large percentage of these cases. The operation as performed on most of these patients was a modification of that first introduced by T. C. Mar- tin, of Cleveland. It was a delicate operation, requiring considerable skill and special apparatus ; the results were all that could be wished for. The objections were, first, that without a general anesthetic patients became wearied and restless before the operation was completed ; second, the fact that a general anesthetic was required for a number of cases; third, that in cases of unusually large blood vessels in the valve, considerable difficulty was ex- Fig. 46. Author's Four-Inch Operating Proctoscope. perienced with hemorrhage ; fourth, that the patient was confined to his house or bed or the hospital for from four or five days to a week. The clamp of Gant and the Pennington clip greatly simplified the operation of valvotomy ; so much so, that it AUTHOR'S OPERATION FOR RECTAL VALVOTOMY. 93 could be done in the physican's office without any anes- thesia and in a very few minutes. The objection to the use of these mechanical contrivances was the fact of the possibility of their being carried up higher into the bowel after cutting through and also trauma of the rec- tal mucous membrane caused by the retention and pas- sage of the irregularly shaped, hard, metallic bodies. Author's Operation for Rectal Valvotomy. The au- thor has devised an extremely simple technique which has proved most satisfactory in his hands, and which by reference to the accompanying illustrations can be read- ily understood. The patient is put in the knee-shoulder position, and a large operating size proctoscope inserted Fig. 47. Author's Rubber Ligature Carrier or Valvotomy Needle. after the sphincter has been prepared for it, either by gradual dilatation or by immediate partial divulsion fol- lowing local anesthesia of the parts. The author's liga- ture carrier or valvotomy needle depicted above, is threaded through the eye at the curve with a rubber liga- ture (sizes 5 to 8, French scale). The ligature passes inside of the curve of the needle and should project about half an inch from the point. The needle, which is nine 94 AUTHOR S OPERATION FOR RECTAL VALVOTOMY, inches long and has a handle bent at an angle so as not to obstruct the view, is then passed up around and hooked Fig. 48. : Author's Angular Rectal Scissors. A very useful instrument for any cutting operation performed through the operating proctoscope. through the highest offending valve until the point is projected and the ligature can be clearly seen. This end Fig. 49. Technique of Author's Operation for Rectal Valvotomy. This drawing shows the position of the patient in the knee-shoulder posture with the author's valvotomy needle threaded with a rubber liga- ture transfixing the first rectal valve. EECTAL VAL.VOTOMY. 95 Fig. 50. Author's Rubber Ligature Operation for Rectal Valvotomy. B. Drawn from proctoscopic view. A. A rubber ligature in place with lead fastener ready for compression. B. Ligature drawn taut, and lead fastener compressed, showing amount of constriction. C. Result three weeks after operation. 96 RECTAL VALVOTOMY. is then grasped by means of a long alligator forcep and the ligature is pulled through until it is outside the proc- toscope. The needle is then passed back and around the edge of the valve and is brought down also outside the proctoscope and is then taken off the ligature. The liga- ture is now in place (see figure 50, A). Over the ends is slipped a lead fastener or large perforated shot, the liga- ture being put on the extreme stretch and the shot grasped and pushed up to the valve tightly by means of long compression forceps and 'firmly compressed. This puckers the valve (see figure 50, B), and constricts it in such a way that circulation is shut off and the ligature sloughs through in from two to eight days. After the ligature has cut through, the edges retract so that a large U-shaped opening is left, which gradually still further retracts. Fig. 50, C shows the retraction in cases in which the rectal valve contains a considerable amount of fibro-elastic tissue. The advantages of this simple technique are as fol- lows: First. It can be done without any anesthetic whatever. Second. It can be done quickly; that is, the whole operation should not require more than ten minutes for three valves. Third. It requires few instruments or appliances. Fourth. The patient is not confined to bed. Fifth. There is absolutely no hemorrhage ; no stitches are required. Sixth. The rubber ligature, being soft and non-irritat- ing, does not scratch or bruise the bowel in situ or during its expulsion, and there is no danger of its doing damage if it should by any possibility be carried up higher into the bowel. Seventh. It is simple. CHAPTER V. FECAL IMPACTION. This consists in the formation and retention in some part of the intestinal canal of a mass of hardened feces. In 70 per cent of the cases the fecal impaction is found in the rectum and in 20 per cent in the sigmoid flexure. The other 10 per cent are found in the upper portions of the intestinal canal which do not come within the scope of this work and will not be discussed. Causes. Over-distension of the bowel caused by con- stipation may lead to the formation of a pouch or diver- ticulum. This pouch becomes filled with fecal matter and on account of the atonic condition of its muscular fibres, is unable to completely empty itself during defecation. This leads to absorption of the fluid constituents of the stool and leaves behind a hardened fecal mass whose con- sistency ranges from that of stiff clay to calcareous, as in enteroliths, or fecal concretions, which are composed largely of lime salts. Bits of bone, fruit and vegetable seeds, fruit stones, indigestible vegetable fibre, concre- tions of bismuth, salol, magnesia, or other insoluble drugs, taken internally, may, become the nidus of a fecal concretion which in turn is frequently the underlying cause of fecal impaction. Gall stones may also be respon- sible for their formation. 97 98 SYMPTOMS. Symptoms. The symptoms of fecal impaction are those of obstipation, coming on rather suddenly with more or less intestinal distension, accompanied with pain in the rectum, and extending to the left inguinal re- gion, and frequently shooting down the left leg. The patient will complain of a frequent desire for stool, but inabilty to accomplish the same on account of a sense of weight and blocking up of the rectum. If the impaction is low he may feel it impinging on the anus following the effort at expulsion. The pressure on, and irritation of the mucous membrane, caused by the presence of this hard foreign body, starts up a hypersecretion of mucus and causes ulceration of the bowel. This causes in many instances a diarrhoea characterized by frequent, small, irritating, watery, and mucous stools which often contain blood and frequently pus. Cases have been reported in which the impaction has become channelled, where after a period of almost com- plete obstruction, the patients have had stools apparently normal. In cases where the impaction occurs in a pouch, or diverticulum, this may also occur. In these cases, how- ever, the feeling of weight, heaviness, and discomfort in the sigmoid or rectum is still present and there is more or less tenesmus and an unsatisfied feeling after stool. In women, pressure from a large impaction on the uterus, or ovaries, may cause anterior displacement and symptoms of uterine irritation. Through direct pressure and reflexly, the bladder becomes irritable and frequent micturition results. Patients suffering from impaction usually present in addition to the foregoing, symptoms of auto-intoxication, such as dizziness, headache, coated tongue, foul breath, indigestion, with or without vomiting, DIAGNOSIS AND TREATMENT. 99 abdominal distension, lack of ambition, and general ma- laise. Diagnosis. The diagnosis is not difficult. By recto- abdominal palpation, the round, or often nodular mass, can be made out in the lower left inguinal region, or in the rectum itself. To the examining finger in the rectum, it may be hard and nodular, or owing to its being in a pouch or diverticulum and almost completely surrounded by mucous membrane, it may give an impression of being an extra-rectal pelvic tumor. On direct examination with the proctoscope with the patient in the knee-shoulder position, and the rectum inflated, the impaction can be easily made out. It is im- portant in using the proctoscope to so carefully manipu- late the instrument so as to see behind each rectal valve, as not infrequently the pouching occurs in any of these locations and the contained impaction, or concretion, is almost completely hidden from sight. If palpation dis- closes a mass in the sigrnoid flexure examination with the sigmoidoscope may be resorted to in order to demon- strate the impaction or concretion to the eye. It is important to determine either by ocular inspection, or examination with a sound, whether we are dealing with an impaction of clay-like consistency, or a hard concre- tion, as the treatment of the two is necessarily somewhat different. Treatment. The treatment of this condition consists of the prompt removal of the impacted mass. Situated in the rectum and reached by the finger it may be easily broken up without the use of any instrument, providing it is of recent origin and its consistency not firmer than stiff clay. When it is situated beyond the reach of the 100 TREATMENT. finger or if of too firm a consistency to be easily manipu- lated, the injection of 8 or 10 fluid ounces of liquid albolene, olive, or cotton seed oil through a rectal tube large enough to reach well into the sigmoid, and this allowed to remain for 12 hours; will often so soften and separate the mass that it can be passed without any dif- ficulty. In many cases this will bring the impaction down so low into the rectum that it can be broken up with the finger or a dull spoon curette used through the procto- scope with the patient in either the lateral or lithotomy position. The most reliable method is, however, the injection of peroxide of hydrogen in solutions varying in strength from 10 to 25 per cent. With the patient in the lateral position, 2 to 4 oz. of peroxide solution is injected through a soft rubber rectal tube inserted up to the impaction. The tube is allowed to remain in place and at the end of 5 minutes the rectum irrigated; when it will be found that the impacted mass has been disintegrated through the mechanical action of the liberated gas and is easily washed out. Several injections of the peroxide solution may be necessary but if persisted in, it may be relied upon to do the work. When the mass is of long standing and so hard that it takes on the characteristics of a true concretion, it may become necessary to dilate the sphinc- ters under local anesthesia and to break up the mass with a short jawed lithotribe passed through an operating size proctoscope. When the concretion is larger than li/> inches in its widest circumference it is safest and best to administer nitrous oxide, divulse the sphincters, crush the concretion, and remove the fecal mass with forceps. AFTER TREATMENT. 101 After the impaction has been removed, the patient should be put on a liquid, absorbable diet for two or three days. Liquid albolene should be administered in doses of one or two teaspoonsful four times daily and regular daily defecations encouraged. The atonic condition of the rectum should be overcome by the use of the author's pneumatic massage bag as outlined in the chapter on the treatment of chronic constipation. CHAPTER VI. PRURITUS ANI. Pruritus Ani is probably the most annoying symptom which accompanies any disease of thtf rectum. It is be- cause of the intense suffering and discomfort which it causes when present, that it has been given the promi- nence and importance that is accorded it of treating it as if it were a disease by itself. Pruritus Ani which is an accompanying symptom of so many different diseases, in reality should not be con- sidered alone as a disease any more than rectal pain or rectal hemorrhage. Like constipation, however, it i s such an important symptom, and often the only apparent symptom, of some diseased condition, that it has been thought wise to emphasize it in this chapter, and lo speak of some of the conditions which most frequently cause it. Pruritus Ani may be caused by or accompany every known anal or rectal disease, as well as many diseases affecting other organs or general in character. In other words, it may be caused by : 1. Any disease of the rectum or anus. 2. Any skin disease affecting the anal region. 3. As a reflex from diseases of the bladder, prostate gland, uterus, ovaries, vagina, in fact any part of man or woman's uro-genital apparatus. 102 -, ETIOLOGY. 103 4. General or constitutional diseases. 5. Dietary disturbances. 6. Parasites. 7. Irritation from clothing, detergents, or moisture. The discussion of the various anal and rectal diseases which present Pruritus Ani as a symptom will be taken up in the respective chapters devoted to those diseases. The skin diseases most commonly affecting the anal re- gion are marginal eczema, herpes, erythema, scabies, and folliculitis. Stone in the bladder is not infrequently accompanied by an itching of the anus and perineum. Chronic pros- tatitis, vesiculitis, urethritis, phimosis, and cystitis may also be accompanied by itching of this region. Any disease of the uterus or adnexa may cause itching in the region of the anus and many times the symptom of pruri- tus is caused by some irritating discharge from the vagina. Pediculi, thread worms (oxyuris vermicularis), itch- mite (acarus scabiei), ringworm (trichophyton), are the most common parasites manifesting their presence in the anal region by itching. Among the diseases of a more general character which are frequently found to be the cause of itching at the anus are diabetes, malaria, uric acidosis, nephritis, tuberculo- sis, syphilis, and hysteria. Many patients suffer from an attack of Pruritus Ani after partaking of alcoholic stimu- lants in excess. In others, the excessive use of tobacco, coffee, tea and spices also conduce to the production of this symptom. Some patients are subject to attacks of Pruritus Ani only during the strawberry season, while others have an attack every time they partake of sea 104 ETIOLOGY. foods, particularly of the shell fish family. Some patients possess an idiosyncrasy toward some one food or class of foods, and it is the indulgence in this class only which brings on an attack of Pruritus Ani in this particular individual. In many cases the itching is caused by mechanical irritation of the skin surrounding the anus or by the use of coarse or harsh material in cleansing the anus after defecation. Some writers claim,- that the printer's ink on newspapers acts as a special irritant to the anus. The wearing of underwear colored with dyes which are not fast, as well as the pressure of clothing which fits too snugly in the perineal region; the irritation caused by excessive sweating, particularly in stout individuals ; and those who are forced to work in a high temperature, such as engineers, stokers, moulders, and gas workers; are often responsible for the production of Pruritus Ani. Personal uncleanliness in this region is too often found to be the cause of pruritus, as in other parts of the body. There has been a condition described by some writers as idiopathic Pruritus Ani, because of the presence of itch- ing of the anus alone as the symptom, and the discovery of no other apparent cause for its existence. I do not be- lieve that there is such a thing as idiopathic Pruritus Ani. I have seen cases in my practice where after the most painstaking and thorough search no cause could be found for the itching, yet I believe there was a local cause, only it was not discovered. The fact that some of these cases are cured empirically by stretching of the sphincter muscles would seem to indicate that there might be some local condition irritating the nerve endings which was mechanically relieved by the stretching process. APPEARANCE OF THE ANUS IN PRURITUS ANI. 105 The appearance of the anus and perineum in the pa- tient suffering from Pruritus Ani is quite characteristic the skin around the anus being thrown into numerous, deep folds radiating from the anal orifice (Fig. 51). In those cases accompanied by more or less moisture the skin is white, soggy, and more or less macerated, with here and Fig. 51. Pruritus Ani. This drawing made from a photograph of one of the author's cases, shows the characteristic cracking around the margin of the anus and at the posterior commissure, and also shows the area of irritation of the opposing surfaces of the buttocks. there, small raw areas where the skin has been denuded of epithelium by scratching. In other cases of not so long standing, we find the skin around the anus normal in color but dry with a tendency to scale. The cutaneous folds are not so deep, but in the sulci are found small cracks 106 EXTENT OF IRRITATION AND EXCORIATION. in the skin and extending up into the mucous membrane. In many cases particularly in stout individuals, a long raw fissure^or crack may be found extending along the median raphe anteriorally to the scrotum or posteriorly into the median perineal crease for a distance of from one Fig. 52. External Integumentary Hemorrhoids Accompanied by Pruritus Ani. This photograph of one of the author's cases, shows the extent to which cutaneous irritation may go ; in this case extending up over the sacrum and down nearly half way to the knees. to four or five inches. The skin surrounding the anus and these various cracks may be reddened and excoriated for a great distance from the lesion. It may extend some distance up onto the abdomen or down the thighs (Fig. CHARACTERISTICS OF THE ITCHING. 107 52) and legs to the knees In cases of long standing the skin surrounding the anus loses its elasticity and becomes hard, thick, and leathery. This condition is in reality due more to the scratching and rubbing by the patient in his futile efforts to relieve the condition, than to any patho- logical condition brought about by the itching itself. Pruritus Ani may mean anything from a slight feeling of uneasiness or irritation in the anal region to an intense burning, almost crazing, itching characteristic of the most aggravated types. There are several things character- istic about this itching: 1. It is usually more intense at night. 2. It tends to become progressively worse. 3. It is not relieved by scratching. 4. In spite of the fact that the sufferer soon realizes that the scratching or rubbing only aggravates the con- dition, he persistently and constantly continues to scratch. While every disease affecting the rectum or anus may be responsible for the production of Pruritus Ani, those that most commonly cause it are fissure of the anus, ul- cer, particularly of the anal canal; fistula-in-ano either complete or blind, hypertrophied papillae and proctitis. The reader is referred to the respective chapters describ- ing these conditions with their diagnosis and treatment. Every case of Pruritus Ani demands the most careful in- vestigation, into the patient's habits, occupation, and mode of living ; as well as the most thorough examination of the anus, rectum, sigmoid, and adjoining organs. Unfortunately in some few cases where pathological conditions have been found in the anus or rectum, which were thought to be the cause of Pruritus Ani, their re- moval has not relieved the itching. In fact, on account of 108 NON-SURGICAL TREATMENT. the healing by granulation and the resultant scar tissue, some cases have been reported in which the itching has been aggravated. It is important, therefore, to be very guarded in the prognosis and not promise a cure. The treatment of Pruritus Ani is of course the treat- ment of the disease, whether local or general, which causes it; and the reader must use his general medical knowledge in the treatment of diseases of a constitutional nature and in treating those of the general diseases men- tioned above, as that does not come within the scope of this work. The treatment of the symptom itching, must be simply palliative, while the treatment of the condition which is responsible for the itching is being carried out. If due to any of the rectal or anal diseases mentioned herein, follow out the treatment as laid down in the various chapters. If due to any skin disease of the part such as marginal eczema, consult any good work on der- matology and treat it as you would any other skin disease in any part of the body. The author has found the fol- lowing ointment a most successful one in these cases: V Pv. Calamine 2 drachms. Zinc Oxide 1 drachm.. Calomel 15 grains. Ac. Phenic 20 drops. Lanolin 1 ounce. M. Ft. Unguentum. This is applied freely to the parts after cleansing and thoroughly drying, after each bowel movement and at night. In some cases where there is considerable moisture the following powder may be used instead of the ointment : NON-SURGICAL TREATMENT. 109 V Chloretone 30 grains. Pv. Calamine 2 drachms. Zinc Oxide 1 drachm. Calomel 30 grains. M. & Ft. dusting powder. This is applied in the same manner as the ointment. Herpes and erythema of the skin surrounding the anus may be relieved by the application of the Compound Stearate of Zinc with Balsam Peru. The parts must be protected and the surfaces kept from rubbing against each other by absorbent cotton. Scabies is best treated by the ordinary sulphur ointment of the pharmacopoeia. Where inflammation of the hair follicles exists with the formation of pustules they must be opened, washed with a 25 per cent solution of peroxide of hydrogen and then dressed with a compress of any of the standard antiseptic solutions, boracic acid being used by the author. Where the pediculi pubis is suspected, liberal applications of blue ointment or fluid extract of larkspur should be used. In ring worm, the trichophyton may be reached by sulphur ointment. Where thread worms are present, lime water enemata will very quickly relieve. It should be injected twice daily using from 4 ounces to i/^-pint at each sitting and capsules containing one-half grain calcium sulphide, given three times daily before meals. In cases where excessive indulgence in smoking, alco- holic stimulants, and articles of diet which produce or aggravate itching is responsible ; it is obvious that these indulgences must be interdicted. Where the occupation or habits- are at fault, changes are necessary in order to bring about the best results. The remedies or combina- HO NON-SURGICAL TREATMENT. tion of remedies which are recommended for Pruritus Ani are many. Blackwash is recommended by many au- thorities as an old reliable remedy. Tuttle considers car- bolic acid in ointment or solution from five to twenty per cent as the most generally applicable of all drugs for the relief of Pruritus Ani. He recommends this pre- scription : Ac. carbolici 2 drachms. Ac. salicylici 1 drachm. Glycerine 1 drachm. M. sec. art. Sig. Apply to the parts with camels' hair brush or cotton swab softened in hot water. Cripps recommends : Acidi Carbolici V 2 drachm. Unguentum hydra rg. nitratis 2 drachms. Ung. Petrolii 1 ounce. Another ointment of which he speaks very highly of is: Extracti conii 1 drachm. Olei ricini 1 drachm. Ung. lanolini, ad 1 ounce. Where ointments do not agree Kelsey recommends this lotion : Sodii biboratis 2 drachms. Morphiae hydrochlor 16 grains. Acidi hydrocyanic Dil y 2 ounce. Glycerine 2 ounces. Aquae, ad __ 8 ounces. Cripps also recommends a lotion containing 2 grains of bichloride of mercury to the ounce of lime water as an NON-SURGICAL TREATMENT. Ill application, after thoroughly washing the parts with soap and water. Gant recommends as a hard ointment the following : 9 Carbolic acid 20 grains. Menthol 10 grains. Camphor 10 grains. Suet 1 ounce. M. Sig : Apply freely 2 or 3 times daily after cleansing the parts. In the preparation of the above he advises to melt the suet and when partly cooled to add the other ingredients. He especially cautions against adding oil as the ointment should be quite hard, the object being to form a coating over the parts which will not be penetrated by the secretions. Citrine ointment (unguentum hydrar- gyri nitratis) is highly recommended by Gant in cases where it is necessary to restore the circulation and the indurated skin to its normal color and suppleness. Through the suggestion of Dr. L. H. Adler, Jr., Gant uses it in the following manner: After the parts have been bathed in warm water the citrine ointment (which may have to be weakened in some cases by the addition of lard) should be spread on several thicknesses of gauze, applied, covered with oiled silk, and held in place by a snug T-bandage. This ointment should be kept on constantly, or in some cases it may be found necessary to alternate it with an ointment containing 20 grains of calomel to an ounce of petrolatum. In the author's experience for the mere relief of itch- ing, compresses or enemas of water as hot as can be borne has given the greatest relief in the greatest number of cases. Sometimes cold acts better than hot. An ointment 112 MECHANO-THERAPY. containing twenty-five per cent of chloretone in white cold cream has proven very efficacious in the author's hands for the same purpose. In cases presenting a fissured condition of the anus skin and mucous membrane, the application of 100 per cent solution of nitrate of silver will cause a desquama- tion of the entire surface within 24 hours. Then a 5 per cent solution of ichthyol in flexible collodion is applied on alternate days. The use of a mechanical vibrator, using a cone-shaped vibratode for five minutes at a time, using from 5000 to 7000 strokes a minute and inserted as far as can be borne by the patient, will often afford much re- lief. Firm pressure by means of a hard rubber rectal plug affords relief to some individuals where all other measures have failed. It must be borne in mind that while any of the remedies mentioned herein are being used to relieve the itching, that they are but palliative, and the permanent relief of the itching comes only after the diagnosis and cure of the condition which causes it. This must be diagnosed and studied for treatment and if the condition is not amenable to nonsurgical treatment or operative treatment under local anesthesia it is more like- ly a case for the proctologist than for the general prac- tioner, and his aid should be called in. If the itching is caused by the discharge from rectal cancer or from the small, shallow ulcerations of the mu- cous membrane between the sphincters, which Wallis of London claims is the cause of 90 per cent of all cases of true Pruritus Ani then the indicated surgical pro- cedures should be carried out, whereupon the itching will be relieved. The writer would suggest that one should carefully read over the chapters on constipation, anal SURGICAL TREATMENT. 113 fissure and ulcer, fistula, hemorrhoids, and hypertrophied papillae, as well as the chapter on the examination of the patient before attempting to treat a case presenting Pruritus Ani as a symptom. In many cases, the local condition seems to imperatively demand surgical treatment, and in many of these patients prompt relief is experienced after the indicated opera- tion. The author describes below those which he can safely recommend. Fig. 53. A Simple and Satisfactory Rectal Dressing. Consisting of a gauze covered cotton pad and two strips of adhesive plaster. 114 HAMILTON'S OPERATION. Surgical Measures. In those cases of Pruritus Ani in which the skin surrounding the anal orifice has been hypertrophied and thrown into heavy folds and the sulci between these folds fissured, irritated, and giving forth an irritating discharge ; a simple surgical procedure will often give relief. E. A. Hamilton, of Columbus, 0., ad- vises the removal of these hypertrophied skin folds under local anesthesia, and reports very good results from his method. Where there are only two or three folds involved, they can all be removed at one sitting. Otherwise, the opera- tion may have to be done at different sittings, with inter- vals between long enough to allow of complete healing of the ones already operated upon. After cleansing, sterilizing and shaving the parts, the patient is placed either in the lithotomy or lateral position. Each fold to be removed is injected from its outermost point with % to 1 per cent solution of eucain lactate. After allowing a couple of min- Fig. 54. Sharp Pointed Scissors Curved on the Flat. utes for the anesthetic to take effect, the fold is re- moved by grasping its apex with a pair of forceps and cutting it out at its base with a sharp scissors curved upon the flat or by elliptical incisions with the seal- REMOVAL OF POSTERIOR TRIANGULAR FLAP. 115 pel. The other fold or folds are treated in like manner and the wound surfaces allowed to heal by granulation. The bowels are kept confined for three days, and then moved by the administration of a heaping teaspoonful of compound licorice powder on the evening of the third day, followed the next morning by an oil enema of six or eight ounces. Applications of bovinine three or four times daily to the wound surfaces will greatly hasten healing. After two or three weeks another two or three folds, preferably those situated opposite to those pre- viously removed, can be dealt with in a like manner and the same technique carried out until all the redundant tissue has been removed. Where the pruritus is most persistent at the posterior commissure of the anus, and examination at that point shows either nothing but a thickened and irritated area extending a short way into the anal canal, or shallow excoriations at the anal margin which are neither fis- sures or ulcerations ; the removal of a triangular flap of skin at this point is often followed by relief of the symp- toms. The technique is as follows: After cleansing, steriliz- ing and shaving the parts, a point three-quarters of an inch behind the posterior commissure is selected and one- half of one per cent solution of eucain lactate injected so as to include a triangle whose apex is the point of injec- tion and whose base extends from one-quarter to one- half inch to either side of the posterior anal commissure. The infiltration of the anesthetic solution should extend up into the anal canal far enough to include any exco- riated or irritated areas. A triangular flap of skin is dis- sected up by means of the sharp scalpel or sharp pointed 116 BALL'S OPERATION. scissors curved upon the flat starting at the point of in- jection and extending to the posterior margin of the anus. The incisions then should be brought towards each other so as to meet at a point one-quarter of an inch above the diseased area in the anal canal. The latter part of the operation makes a short, broad triangle whose base is the same as the base of a longer one on the skin surface. This leaves a denuded area kite-shaped as it were. The skin is brought together by three or four No. 1 or 2 chromi- cized cat gut sutures, boro-chloretone powder applied, and the wound protected with a gauze pad held in place by adhesive strips. (Fig. 53.) The care of the bowels is the same as that outlined above, and the after treatment con- sists of daily cleansing of the parts and re-application of boro-chloretone or compound stearate of zinc powder. Healing will take place in from four to seven days and the relief experienced by the patient after this procedure in selected cases is very satisfactory indeed. Ball's Operation. Perhaps the most successful sur- gical measure for the relief of persistent Pruritus Am', which is available for employment under local anesthesia, is the ingenious operation devised by Sir Charles Ball, of Dublin. As described in Ball's work on "The Rectum", its em- ployment is advocated under general anesthesia. The author, however, has been able to perform the operation with brilliant results by the employment of local anesthe- sia. The object of the operation is for the purpose of di- viding all the sensory nerve twigs supplying the skin of the anus, anal canal and circum-anal region; which arise from branches of the third and fourth sacral nerves, come AUTHOR'S TECHNIQUE FOB BALL'S OPERATION. 117 down to the levator ani muscle, and reach the skin by perforating the external sphincter. The technique as employed by the author is as follows : The patient is given a hypodermic injection of one- quarter grain of morphine and 1-150 grain of atropine and is placed in the left lateral or Sims' position, and the area surrounding the anus cleansed, shaved and sterilized. An ounce of one-eighth of one per cent solution of beta eucain lactate should be prepared and in readiness. Ten or twelve sharp pointed curved needles each threaded with No. 2 chromicized cat gut; a couple of sharp,. small bladed scalpels; sharp pointed scissors curved on the flat; two pairs of T-forceps, and two or three hemosta- Fig. 55. T Forceps. tics, and the syringe for injecting the solution are all the instruments required. Selecting the point about one-half inch behind the posterior extremity of the lines of in- cision in Fig. 56, the skin and subcutaneous tissue is 118 AUTHOR'S TECHNIQUE FOR BALL'S OPERATION. infiltrated. From this point the area included inside the lines in Fig. 56 and for one-half inch beyond, is dis- tended until complete anesthesia is secured up to the ano- rectal juncture. The presence or absence of skin sensi- bility to pain should be tested before starting to operate. Fig. 56. Ball's Operation for Pruritis Ani. Elliptical lines of incision on either side of the anus. From a photograph of one of the author's cases. The incisions, as outlined in the above illustration, are then made with a sharp knife down through the skin to the subcutaneous tissue. The area included between the lines of incision should be of elliptical shape, and about twice as long in the antero-posterior direction as it is broad in the lateral, with the anal canal as its center. With the patient in the left lateral position, the incision AUTHOR S TECHNIQUE FOE BALL S OPERATION. 119 on the left side is made first, the inner flap of skin is grasped with T-forceps, and by rapid and careful dissec- tion with the scalpel is raised from the surface of the external sphincter muscle and freed up to the ano-rectal juncture. The anterior and posterior pedicles between the ends of the incisions are freed from the subcutaneous tissues as well. In other words, all connection between the funnel-shaped cutaneous and muco-cutaneous cover- Fig. 57. Ball's Operation for Inveterate Pruritus Ani. Method of dissecting the flaps and of dividing the terminal cutaneous nerve twigs, which, for the purpose of clearness are somewhat exag- gerated in the drawing. The Rectum: Its Diseases and Developmental Defects. By Sir Charles Ball. ing of the anus and anal canal are freed entirely from their underlying tissues (Fig. 57). Ball advocates the use of the scissors for this work, but the author has found he 120 AUTHOR'S TECHNIQUE FOR BALL'S OPERATION. can work much more rapidly and with more assurance of dividing all the sensory nerve twigs by the use of a sharp scalpel. All bleeding should be controlled by pres- sure with dry gauze, and the flaps sutured again to the surrounding skin with silk worm or No. 2 chromicized catgut. Four to six interrupted sutures are all that are necessary for each incision. Firm pressure by wedge- Fig. 58. Ball's Operation: for Pruritus Ani. The dotted lines, outside of the lines of incision, show the area to which the wound is undercut, and the outside limits of anesthesia pro- duced by the operation. From a photograph of one of the author's cases. shaped gauze pads is brought to bear against the region operated upon, and the dressings held in place by ad- hesive plaster and a T-bandage. This operation by divid- ing all of the sensory nerve branches supplying the area AFTER CARE. 121 most often involved immediately renders this region superficially anesthetic, and the pruritus is relieved at once (Fig. 58). Cutaneous sensation returns after a few months, but pruritus is permanently relieved. The after care consists in keeping the patient on an absorbable liquid diet and keeping the bowels confined for four or five days, when they are moved by an oil enema. The parts are carefully washed and kept pro- tected at all times by the liberal use of compound stearate of zinc powder. The patient should be kept in bed for a day or two and then allowed to be up and about, but not to resume his regular occupation for a week or ten days. In the experience of the author, the results following this operation have been most happy, particularly in those old chronic cases where all other forms of treatment have been tried and found wanting. CHAPTER VII. ANAL FISSURE AND ULCER. Anal fissure, or fissure-in-ano, is probably responsible for more acute pain, suffering and discomfort than any other lesion of its size occurring in the human body. The Fig. 59. Fissure of the Anus. This is a drawing of an old chronic case occurring in the author's practice and well shows the extent to which the ulceration goes in some cases. A well developed sentinel pile will be seen at the lower extremity of the fissure. 122 ETIOLOGY. 123 fissure, as its name implies, is a crack or elongated ulcera- tion, occurring most frequently at the posterior commis- sure of the anus (Fig. 59). Cause. Fissures are caused by trauma. The trauma- tism may be produced either by the passage of an unusu- ally large stool, introduction or expulsion of a foreign body, sneezing, coughing, or by faulty instrumentation. Fissures are usually single. When more than one is present it is an evidence, as a general rule, of the presence of tubercular, gonorrhoeal or syphilitic infection, or a Fig. 60. Multiple Fissure in Ano. This shows the extreme to which anal fissures may go in cases suf- fering from wasting diseases. Drawn from one of the author's cases. 124 ETIOLOGY. run-down condition caused by some one of the wasting diseases (Fig. 60). In men, in 90 per cent of the cases the fissure will be found at, or just at one side of, the posterior anal commis- sure. In women, about 60 per cent the other location being at, or to one side, of the anterior commissure. The reasons that the posterior commissure is the most frequent location for fissure are : The fact that on account of the concavity of the sacrum the curvature of the rectal and anal canal is such, that the greatest force during the expulsion of the stool is towards the posterior commis- sure. Also, the fact must be remembered, that the fibres of the sphincter ani muscle run parallel to each other pos- teriorily (see Fig. 4), to the coccyx; and this is the direc- tion of the anal line of cleavage. Moreover, this is a con- stant location for one of the crypts of Morgagni, and the tearing down of a semi-lunar valve at this point (Fig. 61), is also an important etiological factor in the production of fissure. Any inflammatory condition which will cause a mois- ture and softening of the anal skin will render it more liable to be injured during a movement, and fissure pro- duced. A fissure is, in reality, a longitudinal ulcer. When the fissure has been in existence for some time, it tends to become chronic and the tissues surrounding it become indurated, and the skin is pushed down in the form of a tag which becomes hypertrophied (Figs. 59 and 61) in such a way as to give rise to a thick crescentic fold known as the "sentinel pile." Fissures frequently are found ac- companying hemorrhoids, the ulceration being located in the sulcus between two hemorrhoidal masses. Not in- ETIOLOGY. 125 frequently when the fissure is of the chronic variety, it is accompanied by a polypus, which by hanging down into the fissure from its upper extremity, tends to keep Fig. 61. Fissure in Ano Resulting From the Tearing Down of One of the Crypts of Morgagni With the Formation of a "Sentinel Pile." 126 DIAGNOSIS. it; ' irritated and prevents it from healing. One reason advanced for the fact that fissures or ulcerations in the anal canal tend to become chronic rather than to heal, is the fact that the anal canal is lined by a layer of thin transitional epithelium which is neither mucous mem- brane nor skin, and is poorly supplied wth blood. This fact, and the action of the sphincters keeping the parts in motion, tend to prevent good healing. The diagnosis of fissure is comparatively easy. A pa- tient presenting himself with a history of sharp, cutting, often excruciating pain, accompanying the passage of a hard stool, and the appearance of hemorrhage following the passage, is in itself almost pathognomonic of the production of a fissure. Added to this the history of pain, usually very severe, as well as the appearance of blood with each succeeding stool, is corroborative. When the patient also complains of a beating, throbbing pain lasting from half an hour to several hours following the passage and painful spasmodic contractions of the anal sphincter, or Pruritus Ani, the diagnosis of fissure-in-ano is almost conclusive, without an examination. However one can never take the diagnosis of any condition in the anal or rectal region for granted, without making a thor- ough examination. Therefore, after obtaining such a history, the patient should be placed on the table in the lateral position for examination. Upon separating the buttocks, the first thing that will usually attract attention, except in acute cases, is the presence of a sentinel pile. This gives a clue at once to the location of the fissure, which will be found, as above stated, almost always at, or to one side or other, of the posterior anal commissure. Inasmuch as the entire DIAGNOSIS AND TREATMENT. 127 sphincter is inflamed, hypertrophied and exquisitely sensitive to the touch, it may be necessary, before a satis- factory examination can be made, to anesthetize the parts. However, if by gentle traction on the skin, just below the sentinal pile, a red raw abrasion is disclosed, extend- ing upward into the anal canal, the diagnosis of fissure is confirmed. If this procedure causes much suffering to the patient, it had better be abandoned until the sphincter has been anesthetized according to the technique outlined' in Chapter XV. In cases which have existed for some time, the fissure instead of presenting a red angry appearance, may be covered with a grayish or yellowish exudation. The rea- son that a fissure or ulceration of this region is so exquis- itely tender is because of the exposure of some of the numerous nerve endings with which this region is so gen- erously supplied. The only other condition with which fissure is liable to be confounded, is hemorrhoids, and that only from the patient's standpoint. Not infrequently practitioners have been led into the error of taking the patient's word for the fact that he was suffering from hemorrhoids, because of the symptoms of pain at stool and hemorrhage; and the author would reiterate at the risk of becoming tiresome, that a rectal examination must be made in every case, when the exact diagnosis can be easily made. Treatment. The treatment of fissure in ano resolves itself into palliative and operative. Many cases of fis- sure of recent origin are entirely amenable to non-surgi- cal treatment. The first thing to do is to relieve constipa- tion, which is done by putting the patient on a suitable diet, excluding all such articles as leave much residue and 128 NON-SURGICAL TREATMENT. cause bulky stools. The administration of white petro- leum oil, suitably flavored, in doses of from four drachms to an ounce daily, will soften the stools to such an extent as to make them easy of expulsion and yet not liquid and irritating. Where the fissure is shallow, and is not accompanied by the formation of a sentinel pile, the application of a swab moistened in four per cent eucain solution, for four or five minutes, followed by the application of pure ichthyol to the surface of the fissure, is very efficacious. Fig. 62. Method of Applying Ointment to the Anus from a Long Nozzled Collapsible Lead Tube. This is repeated every second day. In the meantime the patient is instructed to carefully cleanse the parts after bowel movements and to apply, by means of a long noz- zled ointment tube (Fig. 62) the following: NON-SURGICAL TREATMENT. 129 Chloretone _______________________ gr. xxx Thymol iodide ____________________ gr. xx Ichthyol ____________________________ gr. xxx Lanolin ___________________________ qs.o ss. M. Ft. Unguentum. In other cases, the application of a mixture containing 10 per cent of ichthyol and 8 per cent of chloretone in flexible collodion, will be sufficient. The application is made by means of a swab, or directly from the long noz- zled ointment tube; the parts being separated with the thumb and forefinger of one hand, while the application is made with the other. Then the parts are thoroughly dried, and the evaporation of the ether hastened by means of the air current. Stearate of zinc powder is applied and a pledget of absorbent cotton protects the parts from the clothes. Occasionally, where the fissure is very superficial and consists merely of a crack in the mucous membrane, a single application of a 100 per cent solution of nitrate of silver will be sufficient. This acts by causing a protective covering of albuminate of silver to be formed and effects the cure. Proper attention to the condition of the bowels, cleanliness and the application of stearate of zinc powder being all the after care that is required. The daily application of mild solutions of nitrate of silver, alum, copper sulphate or the use of the caustic stick are not to be advised, because they only keep up the irritation and destroy the new granulation tissue as fast as it is formed. The stronger solution of silver nitrate, as mentioned above, by its sudden coagulation of the al- bumen of the tissues when it comes in contact with the 130 SURGICAL TREATMENT. wound, causes the formation of an impermeable protec- tive covering for the granulating surface beneath; and, moreover, is far less painful than the milder solutions. Suppositories for the relief of fissure, do not appeal to the author, inasmuch as fissure is always found in the anal canal and the action of a suppository is exerted only in the lower rectal cavity; he fails to see where any direct relief can be obtained from suppositories in this condi- tion. Moreover, it is doubtful whether an ointment ap- plied with the finger is of any value, for it certainly can- not be applied high enough to reach any but the most dependent portion of the fissure ; yet it is astonishing how often the patient suffering with fissure is dismissed with a prescription for an ointment. Surgical Treatment. The best and surest and quickest treatment for fissure-in-ano is incision or excision. The author knows of no operative pro- cedure in the line of proctology from which more satisfactory results are achieved than the incision or excision of an anal fissure. Under local anesthesia, this is very easily and readily accomplished, and the re- sults are invariably all that could be desired. In some cases, where the fissure is of recent origin, not accompa- nied by much inflammatory infiltration of the surround- ing tissues, simple divulsion is all that is necessary to effect a cure. Divulsion of the sphincter, however, can be accomplished to the extent of temporarily paralyzing the muscle, only by the use of a general anesthetic. This can be best, quickest, and most safely accomplished by the use of nitrous oxide, than any other anesthetic. Incision. The technique of incision of anal fissure is as follows: After anesthetizing the sphincter TECHNIQUE OF INCISION. 131 and dilating it, as outlined in the chapter on local anesthesia, a drachm or so of one-tenth of one per cent solution of eucain is injected below and around the fissure in such a way as to raise it up so that it is resting on a "water bed." After wait- ing a minute or two for anesthesia to become complete, an incision is made from the extreme upper end of the fissure down through the center and extending beyond the lower extremity for a quarter of an inch into the skin. The incision should be so made that its upper or inner Fig. 63. Simple Incision of Fissure in Right Posterior Lateral Quadrant of Anus. extremity should be the shallowest, and it should become deeper until at the lower or skin end it is from one- quarter to one-half inch in depth, slanting in such a way that the upper or shallowest part shall be the first 132 INCISION AFTER CARE. to heal and the lower the last thus providing proper drainage. The unhealthy surface should be lightly cur- retted, a suppository containing two grains each of chloretone, thymol iodide and powdered opium inserted, and a single strip of plain gauze placed in the wound. At the end of 24 hours the gauze is removed, but the patient's bowels not allowed "to move for three days at least. In the meantime, he is kept on liquid diet and the administration of white petroleum oil is started on the evening of the second day, so that the first stool will be soft and unirritating. It is advisable on the evening before a stool is desired, to- administer a level teaspoon- ful of compound licorice powder, and the first thing the following morning, to inject through a small rubber catheter, six or eight ounces of olive oil into the rectum to insure a soft and easy movement. The after care consists in keeping the parts clean, the bowel movements soft, and the patient up and about after the first 24 hours. If granulations become flabby or unhealthy in appearance, a single application of 100 per cent nitrate of silver is usually sufficient to stimulate healthy healing. On the other hand, if the patient is in a run-down condition and the healing slow, the insertion of a one-half inch strip of gauze soaked in bovinine. twice daily, will nourish the healing tissues and bring about a speedy result. While in many cases this procedure will be sufficient, it will not answer where the fissure is of long standing, or if surrounded by an area of infiltration, or where there is a well developed sentinel pile or a polypus accompanying the fissure. Ofter a fissure after incision will not heal, because of the fact that the mucous membrane dips down AUTHOR'S OPERATION FOR EXCISION OF FISSURE. 133 into the wound and tends to keep its edges apart. To obviate this, and to make sure that all the diseased tis- sues are removed, the author excises instead of incises. when operating for fissure in ano. Author's Operation. With the patient prepared and anesthetized as for the incision operation (with the excep- tion that the area of infiltration anesthesia is made more extensive so as to include all the induration surrounding the fissure), he proceeds as follows: The fissure is grasped at its upper extremity with sharp toothed for- Fig. 64. Sharp Toothed or Pronged Forceps. This is a very useful instrument in many ano-rectal operations and while originally designed as a tonsil forcep, is of great value in proc- tologic work. ceps and two longitudinal incisions are made, one on either side of the fissure, starting from one-eighth to one- fourth inch to either side of its upper or inner extremity and being made in such manner that they meet underneath the fissure in its median line, forming a V-shaped trench (Fig. 65), as it were, which is one-eighth of an inch deep at its upper extremity and one-fourth of an inch wide; and at the outer or skin portion its width is 134 AUTHOR'S TECHNIQUE. from one-half to three-fourths of an inch and its depth from one-fourth to one-half inch. This disposes of the entire fissure, with its indurated edges, and the sentinel pile as well. It also allows of the fissure FFC.B Fig. 65. The Author's Technique for the Excision of Anal Fissure. A. The dotted lines show the line of incision both on skin surface and mucous membrane. B. Showing V-shaped bed left after removal of the flap containing the fissure ; the dotted lines show the shape and direction of the incision inside of the anus. healing quickest at the bottom and prevents any over- growth of the mucous membrane or dipping down of the edges. If a polypus is situated at the upper extremity, the incisions are carried up to include it. and as the fissure is dissected up from below, a liga- EXCISION OF AXAL ULCER. 135 ture is thrown around the base of the polypus, tied, and the fisure and polypus en masse cut away. The after- treatment is the same as outlined for the incision opera- Fig. 66. Operation for Excision of Anal Ulcer. Note the manner in which the incisions are brought to a point at upper and lower extremities of wound. 136 ANAL ULCER TREATMENT. tion. This operation, in the hands of the author has been so satisfactory that it is his routine treatment for all fissures not amenable to non-surgical treatment. Anal Ulcer. Whatever has been said regarding fis- sure in ano in regard to treatment by non-surgical meas- ures is equally applicable to anal ulcer, the only distinc- tion between the two conditions being a question of the shape of the ulceration the fissure being elongated, while the other ulcers of the rectum are round or irregular in outline. In ulcers which do not respond to the applica- tions advocated for fissure, the injection of a few drops of one-tenth of one per cent eucain solution under the ulcer is advisable, and a light curetting of its surface will often be followed by marked relief. Where the ulcer is of long standing, the excision of the indurated tissues surrounding as well as the ulcer itself should be accom- plished following the same technique as outlined for the excision of fissure, varying the direction of the incision to correspond to the shape of the ulcer (Fig. 66). The after-treatment following excision of an anal ulcer is exactly the same as that outlined above, following fis- sure. It is the watchful after-care of the conscientious physician following many of these minor anal operations which is responsible for the good results for often a well executed operation is nullified in its results by neg- lectful, slovenly or misdirected after-care. Oftentimes the after-care of patients following these operations, is over-done rather than the reverse, and meddlesome inter- ference accomplishes more harm than the operation does good. CHAPTER VII. ABSCESS OF THE ANO-EECTAL BEGION. The region of the anus and rectum is peculiarly prone to infection and abscess formation, for several reasons: The unusual amount of cellular tissues surrounding the rectum; the lavish blood supply of this region; the con- stant presence in the rectum of pyogenic bacteria; the traumatism from unusually large or hard feces, foreign bodies which have been swallowed, such as spicules of bone, fruit pits, seeds, and other articles which have been ingested. The rich lymphatic supply of this region is of no small moment in the production and extension of sep- tic inflammation. Skin diseases around the anus, partic- ularly those which affect the hair follicles, inflammation of external hemorrhoids, the irritation from clothing or harsh detergents, disease of the crypts of Morgagni, rec- tal ulceration and anal fissure all may form the starting point for the formation of an abscess in this region. Septic infections of the ano-rectal region have been di- vided into different classes by different authors. Tuttle classifies them as follows : 137 138 CLASSIFICATION". Circumscribed Inflammations or Abscesses f Subtegumentary. Superficial -i Tegumentary. I Ischio-Rectal. Profound Diffuse Inflammations f Retro-Rectal. J Superior Pelvi- Rectal. [ Interstitial. f Diffuse Perirectal Cellulitis. I Gangrenous peri- rectal Cellulitis. Of the circumscribed inflammations or abscesses, only those which are located below the levator ani muscle are amenable to treatment under local anesthesia and will be considered by the author under the head of tegumentary or perineal abscesses; peri-anal, marginal, or subtegu- mentary abscesses ; submucous or intermural, and ischio- rectal abscesses. Tegumentary Abscesses. ; The tegumentary, or peri- neal abscesses, are really nothing more than pustules, or furuncles of the skin surrounding the anal orifice, or. a pustular inflammation of the hair follicles. They may be brought about by anything which causes irritation of the parts, such as extensive perspiration; discharge from the anus or vagina; chafing from the clothing; infection by the finger-nails in scratching; personal uncleanliness, or the use of harsh detergent materials. The condition may range from a simple acne of the parts to the formation of numbers of typical boils. These cause a slight sense of irritation, smarting or itching, and cause more discom- fort when the patient is sitting or walking than any inter- ference with the function of the bowel itself. Occasion- ANO-BECTAL ABSCESSES. 139 Fig. 67. Ano-Rectal Abscesses. 1. Submucous or intramural abscess. 2. Ischio-rectal Abscess. 3. Marginal or Subcutaneous Abscess. 4. Tegumentary or Cutaneous Abscess. 10 140 TEGUMENTARY ABSCESSES. ally several of these small abscesses may run together, forming a typical carbuncle. This, however, is rather rare in this region. There is usually a slight rise of tem- perature, a degree or two at outside; and more or less irritability of the patient's temper. There are no consti- tutional symptoms. Diagnosis. With the patient in the lateral posture, these abscesses will be seen occurring either singly or in groups as rounded reddened swellings from the size of a large pin head to a hazel nut ; with or without a point of suppuration showing. Treatment. The treatment consists of spraying each abscess with ethyl chloride and opening with a sharp bis- toury. After allowing the pus to escape, the cavity is swabed with 95% carbolic acid. Daily washing of the part with warm saturated solution of boracic acid and dressing with boro-chloretone powder will usually be all that is necessary in the line of after-treatment. The parts should be washed after defecation and protected with sterile gauze and the clothing worn loose so that there is no pressure or chafing from that source to keep up the irritation. If there is a tendency for these little skin infections to recur, it is advisable to treat the patient with a bacterial vaccine made from the predominant germ responsible for the infection. In most cases this will be found to be the staphylococcus pyogenes aureous or albus. Subtegumentary or Marginal Abscesses. The most common abscess developing in the region of the anus is that which occurs deeper under the layers of the skin or lining membrane of the anus, described in the above clas- sification as subtegumentary, also known as peri-anal or SUBTEGUMENTAEY OB MAEGINAL ABSCESSES. 141 marginal abscesses; also as subcutaneous, submucous or intra-mural, depending upon the kind of tissue under which the abscess develops. While often their start- ing point can be traced to a fissure or ulcer, a broken down thrombotic pile, or a diseased crypt, or the trau- matism due to a bit of bone or other swallowed foreign body ; nevertheless, in many cases, the point of infection cannot be determined leading us to the conclusion that the abscess is caused by extension through the lymphatic system, from some more or less remote injury or disease in this region. They may occur at any age, but are less common in children. Symptoms. Occasionally abscesses which occur in this region, particularly the sub-mucous variety, have formed and gone on to a considerable size without causing any other symptoms than a sense of uncomfortableness or fullness in the lower rectum, noticed particularly during defecation. Usually, however, the patient complains first of sharp darting pains in the rectum, which is soon followed by an aching, throbbing pain which is persistent and gradually increasing. This aching extends to the sacral region and the pain often shoots down one or both legs, even to the heel. The patient often complains of difficulty of urination. Defecation is always painful and on account of the feeling of fullness in the rectum, is put off by the patient as long as possible. The pulse rate increases in rapidity and the temperature rises from one to four degrees. The patient cannot sit comfortably and rests his weight on one buttock or the other ; a character- istic posture of patients suffering from acute rectal dis- ease (See Fig. 8), which is almost diagnostic in itself. 142 .SUBMUCOUS ABSCESS. An abscess may often come on in from 24 to 36 hours, and occasionally will rupture before the patient is really aware of the severity of the trouble. These are the cases which are most frequently followed by fistula formation. Examination. With the patient in the lateral posture, often nothing can be determined by ocular inspection unless the abscess be situated at or outside the margin of the anus when it will appear as a rounded swelling, reddened in color, situated most often at one side or other of the posterior anal commissure. On digital ex- amination, its outline can be definitely determined and its extent noted. If seen early, a definite point of fluctu- ation cannot be made out, but the whole abscess has a hard, doughy feel. It is extremely painful to the touch and, on account of the accompanying spasmodic contrac- tion of the sphincter muscle, it is often very hard to examine. Submucous Abscess. The submucous or inter-mural variety occurs underneath the mucous membrane cover-' ing the lower rectum, and may be found at any point in the circumference of the rectum. Those located in the anterior wall are usually accompanied by disturbances of urination. In fact r often times patients are unable to urinate at all and have to be catheterized. This variety is diagnosed by digital examination the well lubricated finger, gently inserted through the anus while the patient is asked to bear down. A rounded mass may be felt with- in an inch or inch and a half of the anal outlet, either of a doughy consistency or distinctly fluctuating. By gently sweeping the finger from side to side, the outlines can be made out and its extent determined. With the short ano- scope, the diagnosis can be further confirmed (Fig. 68), SUBMUCOUS ABSCESS DIAGNOSIS AND TREATMENT. 143 and not infrequently the point of infection determined. Occasionally, the abscess may extend down to the integu- ment outside of the anus, forming a submuco-cutaneous abscess. Fig. 68. Proctoscopic View of Submucous Abscess of the Rectum. Diagnosis. The diagnosis, after both digital and ocu- lar examination, is very evident. Given the symptoms of rise in temperature, rapid pulse, aching, throbbing, pain coming on more or less suddenly in the region of the anus or lower rectum and remaining; becoming more persist- ent and increasing in severity, with the presence of a cir- cumscribed painful swelling, makes the diagnosis of ab- scess in this region conclusive. Treatment. The treatment of the sub-cutaneous or marginal variety is very satisfactorily accomplished un- 144 TREATMENT OF SUBCUTANEOUS ABSCESS. der local anesthesia. If the abscess is situated at or below the juncture of the anus and rectum, it will not be nec- essary to anesthetize the sphincter muscle. With the patient in the lateral or lithotomy position, the parts are scrubbed, shaved and sterilized, and the skin over the abscess injected with i/o of one per cent solution of beta eucain lactate. A point a half-inch below the abscess proper is selected for the first injection, and the injection carried upward so that a wheal or welt a quarter of an inch to half an inch wide, and extending the entire length of the abscess, is formed. After waiting two minutes for the anesthetic to take effect, an incision is made from one extreme of the abscess to the other in a direction radiat- ing from the anus, and the pus allowed to escape. It is then syringed out with sterile water or normal salt solu- tion, and after breaking down any dividing walls, so as to convert the abscess into one cavity, it is swabbed out with equal parts of tincture of iodine and carbolic acid, a light gauze drain inserted, and a sterile dressing ap- plied. The patient is not allowed to arise from the table for five or ten minutes after the operation, when he is slowly assisted to his feet, and after a few minutes in a chair will be able to go about his way. It is advisable to keep the patient on an absorbable diet for a couple of days and not allow the bowels to move during that time. The wound should be dressed daily, being syringed with plain sterile water or salt so- lution and lightly packed with gauze. When the author says lightly packed, he means the gauze should be in- serted sufficiently firm to keep the wound edges well sep- arated and yet touching against the lining of the cavity TKEATMENT OF SUBMUCOUS ABSCESS. 145 proper so lightly as not to interfere with its contraction during the healing process. At the end of the fourth or fifth day in the average case the packing can be dispensed with and a strip of gauze inserted for drainage and merely to keep the wound edges apart. The best protective powder to use to keep the discharge from irritating the surrounding skin is compound stearate of zinc with balsam peru or boric acid. Fig. 69. DeVilbiss Rectal Speculum. This instrument is useful in many anal operations, on account of the fact that its blades may be opened parallel to each other and it can be made self-retaining. When the abscess is of the sub-mucous variety and sit- uated above the internal sphincter, it will be necessary to anesthetize the sphincter according to the technique out- lined in Chapter XV. After washing out the rectum with saturated solution of boracic acid, the patient is placed either in the lithotomy position, if the abscess is situated on the anterior wall; or the lateral position, if located on the posterior or lateral wall. After the parts are washed, shaved and sterilized and the sphincter anes- thetized, it is slowly dilated and a Sims retractor in- serted at a point opposite the abscess and held by an assistant. In the absence of an assistant, a De Vilbiss rectal speculum (Fig. 69) will answer, as it is self retain- ing. The mucous membrane covering the abscess is 146 TREATMENT OF SUBMUCOUS ABSCESS. injected with a 1-10 of one per cent solution of eucain lactate or sterile water until the tissues are blanched over tjie entire abscess. After waiting two minutes for the anesthetic to take effect, the abscess is opened by a longitudinal incision extending from its extreme upper end down to a half inch below its lower extremity. The pus is allowed to drain out, when it is syringed with normal saline solution or sterile water. All dividing walls are broken down so that the abscess is converted into one cavity. It is then swabbed out with 95% carbolic acid or equal parts of carbolic acid and iodine, and packed with gauze, which should extend out through the anus. In some cases it is advisable to insert a rubber drainage tube about the size of a lead pencil, which tube should also extend an inch out- side of the anal canal. The after-care is similar to that advised for the sub- cutaneous variety, especial care being taken to see that the abscess is kept healing from the bottom, and that no ramifications form during the healing process. The pa- tient is allowed to be up and about immediately after the operation, and is properly kept up on account of better drainage in the upright position. It is this variety of abscess which if allowed to open without surgical inter- ference forms the blind internal fistula. It is an im- portant thing to remember in this variety of abscess par- ticularly, that the incision should be carried well below the lower extremity of the abscess, so as to allow of good drainage. Ischio-Rectal Abscess. Ischio-rectal abscesses are the most severe variety which can be treated under local an- esthesia, and not all of these, by any means, are favor- ISCIIIO-RECTAL, ABSCESS ETIOLOGY SYMPTOMS. 147 able cases. The author would lay down the rule that no abscess of the ischio-rectal region ivhose upper extremity is over two inches from the anal skin, and whose extent, size and location cannot be definitely outlined by bi-man- nal palpation, should be operated on unless under a gen- eral anesthetic. Ischio-rectal abscesses start, grow and extend with great rapidity on account of the loose cellular tissue in which they form, which offer little or no resistance to iheir spread. They occur at either one side or the other of the rectum, and occasionally surround it. They are formed either from the puncture of the rectal walls by spicules of bone, bristles, or other sharp foreign sub- stances which are swallowed; or from diseased Morgag- nian crypts or infection which is carried by the lymph- atic system. They have been known to follow operations upon the rectum and anus, or injury through faulty in- strumentation in making a rectal examination. Symptoms. The constitutional symptoms are similar to those which accompany the subcutaneous or submucous abscesses with the exception that the pain is more deep- seated, the sacral aching more severe, and the symptoms in general approaching more nearly that of a general septic infection. The patient often suffers from chills with a high fever, severe headaches, backache, fetid breath, languor, loss of appetite, and more or less pros- tration. The pain localizes itself to one side or the other of the rectum unless there is a simultaneous formation of abscesses on both sides. Defecation is so painful that the patient gives up all attempts at it and frequently is not able to urinate as well. If the abscess has existed longer than 48 hours or so, some redness of the skin will ISCHIO-EECTAL ABSCESS DIAGNOSIS. be met with, varying in degree according to the nearness to the integument of the location of the abscess. Fig. 70. Line of Incision for Opening an Ischio-Rectal Abscess. From a photograph of one of the author's cases. Diagnosis. Bi-manual rectal palpation with one fin- ger in the rectum and the other hand pressing towards it just outside of the anus (Fig. 70) will disclose a hard elongated mass, often pear-shaped, which is extremely painful, and gives the characteristic doughy or boggy feel of an abscess. A point of fluctuation oftentimes can be made out at either extremity of the abscess. The diagnosis is readily made by bi-manual examina- tion. The swelling caused by the abscess may be so great ISCHIO-RECTAL ABSCESS TREATMENT. 149 that it is practically impossible to introduce the procto- scope into the rectum. Treatment. After the rectum has been flushed with a saturated solution of boracic acid, the patient is placed in the lithotomy or lateral position, according to the location of the abscess, and the parts washed, shaved and sterilized. The sphincter is anesthetized according to the technique outlined in Chapter XV, and the skin over the abscess, as well as the anal lining membrane, is infiltrated with one-half of one per cent solution of eu- cain lactate. After the infiltration of the skin, the sub- cutaneous tissues down to the abscess cavity are inject- ed with one-tenth of one per cent solution of eucain lac- tate, care being taken not to penetrate the abscess cav- ity with the hypodermic needle. The infiltration should be carried well into the lower rectum. A Sims retractor is inserted at a point opposite the abscess and held by an assistant, or the De Vilbiss speculum used, and opened to its fullest extent. With a sharp pointed bistoury an incision is made from the outermost point of the abscess on the skin towards the anus, so that the incision is at right angles to the anal canal. The opening should be made free enough so as to thoroughly drain the abscess cavity, and, if necessary, should be extended through the sphincters into the anus. Where the abscess cavity can be well exposed by an incision which stops short of the sphincters and there are no ramifications of the cavity, it will not be necessary to enter the rectum, and the author as a rule would cau- tion against making an opening in the rectum unless a communication already exists in the form of a fistula. All trabeculae and partition walls should be broken down 150 ISCHIO-RECTAL ABSCESS TREATMENT. so that the abscess is converted into one cavity, and it should be well irrigated with saline solution or sterile water. The incision at the lower point of the abscess cavity should be as wide or wider than the cavity itself. After irrigating the cavity, sufficiently gauze soaked in Balsam Peru should be gently inserted so as to keep its walls apart and lightly packed. A dressing is applied and the patient advised to keep in the recumbent posi- tion, lying preferably on the side where the abscess is located for 24 hours. At the end of that time, the packing is removed and about two-thirds of the quantity of gauze used in the first dressing inserted lightly. At each succeeding daily dress- ing the amount of gauze is lessened until the abscess cav- ity has healed up from the bottom. If the granulations become flabby or unhealthy at any time, they should be touched up with a stick of copper sulphate or a swab moistened with 25% solution of silver nitrate. The ap- plication of pure ichthyol every second or third day, while somewhat painful, is of extreme value in promoting good granulation. Where it has been found necessary to carry the incision into the rectum and sever the sphincter, care should be taken to arrange the packing in such a way as to pre- vent the skin or mucous membrane from growing down into the wound, thus preventing the reuniting of the sphincter as the abscess cavity heals. If this should happen, however, in spite of all precau- tions, anesthetize the part by the application of a swab soaked in four or five per cent eucain solution for five minutes, keeping up pretty steady pressure on the parts. Then with a pair of sharp pointed scissors curved on ISCHIO-RECTAL ABSCESS TREATMENT. 151 the flat, trim back all redundant tissue to the surface of the skin or mucous membrane as the case may be. In the treatment of all suppurative conditions of the ano-rectal region, the author would caution his readers to refrain from attempting to operate on any case in which there is the slightest doubt of his ability to com- plete the operation under local anesthesia. One must be sure of the size, location and extent of the abscess, and it must be definitely outlined and definitely circumscribed in order to be amenable to treatment under local anes- thesia. CHAPTER IX. FISTULA IN ANO. A fistula may be described as a tubular suppurating tract communicating with, or connecting the mucous mem- brane of the anus or rectum, and the integument contig- uous to the anal outlet. Fistulae are of several different varieties, which will be described below. A fistula is the result of an abscess in the anal region which has either been untreated and allowed to rupture of itself, or when opened by the surgeon has, through insufficient, careless or improper after-treatment, been allowed to contract without being made to heal from the bottom. The only exception would be a fistula caused from a puncture wound, either traumatic or surgical. Fistula in ano is often spoken of as either tubercular or non-tubercular. While the author realizes that tuber- culosis is a factor to be seriously considered in the dis- cussion of fistula in ano, he will reserve his remarks on this particular variety of fistula until further on in the chapter. What is said regarding fistula in ano below, therefore, must be understood to mean the non-tubercu- lar varieties. The reason that an abscess degenerates into a fistula in this region rather than completely heal, is due to two factors peculiar to its location. The most important is 152 CLASSIFICATION OF FISTULAE. 153 the fact that due to the natural motion of the anus and rectum in the act of expulsion of gas or feces, and the dilation and contraction of the sphincter muscle, the parts are not allowed to remain at rest, and the surfaces are prevented from adhering to each other. Added to this is the important fact that mucus and feces enter the abscess cavity from the rectum and their constant pass- age tends to keep the tract open and prevent healing. A fistula therefore is in reality the tubular contracted re- mains of an abscess, and is lined by a pyogenic membrane as was its parent abscess. Varieties. The variety of a fistula depends on the lo- cation and kind of abscess which preceded it. They are divided by some authors into complete and incomplete. A complete fistula being one which gives a direct com- munication between the bowel and the surface of the skin, somewhere in the region of the anal opening. An incom- plete fistula is one which has an opening either into the bowel alone or one which opens through the integument only. Complete fistulae (leaving out of consideration those which communicate with other organs, such as the bladder, vagina or urethra) are divided into horse-shoe fistulae and multiple fistulae. The horseshoe fistula is characterized by its having one opening in the anal canal, usually situated between the sphincters at the posterior commissure; and surrounding the anus, communicates with the skin by two openings one on either side of the anus. A multiple fistula is one which has one or more internal openings and numerous branching channels open- ing by many external openings on the skin. The incom- plete varieties are known as the blind internal fistulae, which are characterized by the fact that they open into 154 SIMPLE, COMPLETE, FISTULA SYMPTOMS, DIAGNOSIS. the bowel only, and blind external fistulae, whose only opening is on the skin. A form of fistula known as the sub-mucous fistula is one which has two openings, both opening on mucous membrane, and is usually found just inside the anal canal. The most common location for the internal open- ing of a fistula is at the posterior commissure of the anus and between the sphincter muscles. In this chapter only those varieties of fistula which are amenable to treat- ment under local anesthesia will be discussed, viz., sim- ple complete fistula, blind external, blind internal and sub-mucous. (Fig. 71.) Simple Complete Fistula. This is the commonest form of fistula met with, and is the remains of a sub- cutaneous or ischio-rectal abscess, and consists of a straight or slightly curved channel running from the anal canal or some point in the rectum a little higher up, to the outside skin usually opening within one or two inches to one side or the other, and below the anal aperture. The external opening may be at any point on the skin in the vicinity of the anus, but the points mentioned are the most usual sites. Symptoms. The symptoms are a sense of irritation or an itching of the anal region, pain during defecation, and the presence of a purulent discharge. If for any reason one of the openings should become plugged up, there is some distension and pain from pressure. Diagnosis. The diagnosis of fistula should always be in mind when on examination of a patient a papule is seen on the perineum or buttocks, from which a drop of pus exudes or can be pressed out. This is the characteristic appearance of the external opening of a fistula, With ANO-KECTAL FISTULAE. 155 Fig. 71. Ano-Rectal Fistulae. 1. Blind internal fistula. 2. Blind external fistula. 3. Complete direct fistula. 4. Submucous or submuco-cutaneous fistula. ll 156 DIRECT, COMPLETE FISTULA DIAGNOSIS. the patient in the lateral position and the index finger of one hand over the external opening, the index finger of the other should be inserted with the palmar surface directed toward the posterior commissure. Often by the Fig. 72. Direct Complete Fistula in Ano. The probe is seen entering the external or cutaneous opening while directly above it its blunt tipped extremity is seen emerging from the anus. Photograph of one of author's cases. pressure with the finger in the rectum a drop of pus will be forced out through the external opening. By care- fully feeling the region between the anal canal and the outside opening, one will often make out the cord like feel of the fistulous tract. Oftentimes the internal open- ing is extremely difficult to find. Upon examination with the author's fenestrated anoscope, or the anoscope with the oblique aperture, a small reddened spot often raised somewhat from the surface will be detected, from which DIAGNOSIS. 157 pus can be squeezed out. When this point is discovered, digital examination will reveal the induration underneath the surface, which discloses the direction of the fistulous tract. If after careful examination of the entire circum- ference of the anal canal and lower rectum, no internal opening can be detected, the injection into the external opening of peroxide of hydrogen, methylene blue solu- tion, or milk of magnesia or bismuth, will assist one in locating the internal opening by the point of appearance of the solution inside the anus or rectum. Fig. 73. Angular Fistulous Tract. The upper portion of the fistula has been opened and the probe can be seen entering the lower portion. The end of the probe can be seen emerging from the left upper quadrant of the anus. Photograph from one of author's cases. 158 SIMPLE DIRECT FISTULAE TREATMENT. The probe may be used to diagnosticate the presence and direction of a fistulous tract, but in order to be of and value it must be very fine and extremely pliable- one made of annealed silver is the best for this purpose. One must be extremely careful in introducing a probe into a fistulous tract, for it is very easy to force it through the walls of the fistula or into the rectum, thus creating a false passage. If the probe does not pass easily it is better to discard it than to use any force in its use. If there is a suspicion that the fistula communicates with the bladder or urethra, the injection of a mild solution of methyl ene blue (1-5%) into the organ will settle the question. If such a communication be present the col- ored solution will exhibit itself at the fistulous opening"" in very short order. Treatment. The treatment of fistula as a general thing is best accomplished under general anesthesia, because many times upon laying open, what appears to be a sim- ple fistulous tract, ramifications and extensions may be found which would necessitate more dissection than is possible to satisfactorily accomplish under local anes- thesia. A case of simple, direct fistula, however, which is not tortuous, and in which the external and internal Fig. 74. Grooved Director. openings, and the line of communication are made out by the diagnostic methods mentioned above, may be treated under local anesthesia in any one of three ways. INCISION TECHNIQUE. 159 Incision. Simple incision will suffice in some cases where the fistula is not deep seated. After the bowels have been washed out with a saturated boracic acid solu- tion and the area around the anus scrubbed, shaved and sterilized, the sphincter is anesthetized according to the technique outlined in Chapter XV, and the tissues over the fistula injected to the point of blanching with one- half of 1 per cent solution of eucain. A probe-pointed grooved director is then passed through the fistula from the external to the internal opening, and all the tissues between the director and the surface divided by a curved bistoury passed from without inward, thus freeing the director and laying open the entire fistula. A pledget of cotton soaked with 4% solution of eucain is pressed into the incision, and is held firmly against the opened fistu- lous tract for two or three minutes. It is then removed and the diseased surface lightly curetted with a sharp spoon curette ; the incision firmly packed with gauze and an anodyne suppository inserted and a dressing applied. Unless the direction of the fistulous tract is in a line at right angles to the fibres of the sphincter muscle, it must not be opened by a single straight incision. It is an invariable rule, that any incision which must sever any or all the fibres of the sphincter, should cross it only at right angles (Fig. 75) in order to prevent incontinence afterwards. The incision therefore must be so directed that it never severs the sphincter muscle in an oblique manner. "Where the fistula is located just below the skin or mucous membrane and does not involve the sphincter, this rule does not necessary hold good. Excision. In some cases it will be found advantageous instead of simply opening the fistulous tract, to excise EXCISION TECHNIQUE. the entire canal. This is the most satisfactory operation when it can be successfully carried out, and should be the operation of choice in all straight, uncomplicated fis- Fig. 75. Right Angled Incision for Simple Direct Fistula in Ano. In a simple fistula by which the bowel communicates with the external integument, crossing the external sphincter in an oblique manner, the external sphincter is cut at right angles by the method outlined. tulae which are situated so that the tissues surrounding the fistula can be sucessfully infiltrated. After the usual preparation of the patient and anesthetization and dilata- tion of the sphincter muscles, the tissues surrounding the fistula are anesthetized. One-half of 1 per cent solution of eucain is injected into the skin along the line of in- cision up to the opening in the anal canal; then the sur- rounding tissues are distended with one-tenth of 1 per cent solution of eucain, care being taken to completely AUTHOR'S TECHNIQUE FOR EXCISION OF FISTULA. 161 surround the fistula on all sides. A grooved director or probe is then inserted and the end, which has been brought through the anal opening, is bent so that it is Fig. 76. Author's Technique for Removing Fistulous Tract in toto. The lateral incisions are so directed that a V-shaped bed is left, which can occasionally be approximated by sutures. exposed outside of the anus. This brings the entire tract into view. The skin is then incised the full length of the fistula down to the infiltrated tissues surrounding it, but not through them. (Fig. 76.) The incisions are then car- ried on either side of the infiltrated fistulous canal in such a way as to free it entirely, and remove it unopened and threaded on the probe. As the incisions are carried around the fistulous tract, they should be brought together in a V- 162 AFTER CARE. shaped manner beneath it. After the removal of the fis- tula, the wound should be packed with gauze,, the anodyne suppository inserted and dressing applied. In the after care following both excision and incision, extreme care must be taken in the daily dressing of the wound to so arrange the packing that it is firm enough to retard too rapid granulation, and yet packed so lightly as to allow the wound to gradually come together. Es- pecial care must be exercised to keep the skin and mu- cous membrane from dipping in or growing down the sides of the incision. If granulation does not proceed as rapidly as it should, the gauze packing should be soaked with bovinine daily before applying, or pure ichthyol or balsam peru should be applied to the granulating sur- faces daily. It is not necessary or advisable to use any of the antiseptic powders in the after treatment of these cases. The bowels are not allowed to move for three days, after which daily movements are not contra-indicated. Where it has been necessary to divide the sphincter either in part or in its entirety, there may be some tem- porary lack of full control of the bowel movements ; but as the wound heals up, control is regained so that no fear need be felt on this score. The patient is allowed to be up and around after the first 24 hours, and can pursue his usual occupation without much discomfort. Ligature Operations. In some few cases where either from the desire of the patient that no cutting operation be done, or some other contra-indication, one may occa- sionally accomplish the cure of a simple direct fistula by means of a ligature either of linen, silk or rubber. The author does not advise the use of the ligature in LIGATUEE OPERATION. 163 cases, as he personally feels that they are never so satis factory, and certainly not as quick in their results as a clean-cut surgical operation under local anesthesia; If A. Fig. 77. Technique of Passing Flexible Silver Probe Threaded With Rub- ber Ligature Through Simple Direct Fistula in Ano. 164 LIGATURE OPERATION. the patient must have a ligature operation, the rubber lig- ature as used by the author in his operation for rectal valvotomy is to be advised, as it is quicker and surer in its results than silk or linen. The ligature is applied in the following manner: A probe is threaded with the material of choice and it is passed through the fistula from without inward; the point projecting in the rectum is grasped with forceps and is pulled through and outside of the anus. The ligature if silk or linen, is then loosely tied so as not to constrict . the parts but lightly surround them and thlTends cut off. This leaves a small loop not unlike a seton. This is moved to and fro every day by the patient and in the course of three to six weeks gradually wears through, the fistula healing behind the ligature, as it works through. In some cases, however, this will not prove efficacious. Where more quick action is desired it is better to use the rubber ligature. It is passed through the fistula, threaded on a probe, in the same manner as the non-elas- tic ligatures, but when it is fastened with a perforated shot, it is put on the stretch. This causes so much pain and suffering to the patient for the first 12 hours that it is necessary to give repeated doses of anodynes. After this period, however, there is comparatively no pain or discomfort until the ligature sloughs its way through, which occurs in the course of from three days to a week. The suffering caused by the use of this rubber ligature is far more intense than that suffered after one of the radical measures mentioned above, and the author can- not conscientiously recommend it except in those cases where other measures are refused by the patient. Blind External Fistula. The blind external fistula is BLIND EXTERNAL FISTULA. Fig. 78. B. Showing Method of Constricting the Area Between Fistula, Anal Mucous Membrane and Skin by Means of the Rubber Ligature Drawn Taut and Fastened With a Perforated Shot. caused by the opening of a peri-anal abscess on the skin surface only. It is characterized by the appearance, af- ter the rupture or opening of an abscess in this region, of a red spot or papule from which pus is discharging. It is accompanied by discomfort to the patient when sit- ting; pruritus ani. or disagreeable moisture in the region, 166 BLIND INTERNAL FISTULA SYMPTOMS. and its diagnosis from complete fistula is made by the method of examination outlined above. In reality it is nothing more or less than a contracted abscess cavity which refuses to heal on account of the action of the sphincter muscle in keeping it open. The treatment consists in the incision with curetting and packing, or excision of the entire fistulous tract. Some authors advise the converting of an external fistula into a complete fistula and then operating as for complete fistula. The author cannot see the reason or advisability of thus converting a simple abscess cavity into a fistula, and would strongly deprecate any such methods. The author does not believe, in fact, knows that it is not nec- essary to divide the sphincter in order to heal a blind ex- ternal fistula. Blind Internal Fistula. This variety of fistula is char- acterized by its having an opening into the bowel only, and is caused by the rupture into the bowel of a peri- rectal abscess whose point of least resistance was to- wards the rectum. They are characterized by their in- sidious and obscure onset and often go for some time undiagnosed. Symptoms. The chief symptom is the appearance of a purulent discharge from the anus. This is accompanied by some smarting, burning, or itching and a feeling of unrest or discomfort in the lower rectum. If there is much involvement of the mucous membrane surrounding this opening there is also a tendency to diarrhoea. When a patient has complained of pain in the rectum persisting for several days, accompanied by heat, throbbing, and rise of temperature ; and these symptoms are more or less relieved just previous to the passage of a quantity of pus BLIND INTERNAL FISTULA DIAGNOSIS TREATMENT. 167 from the anus the breaking of a sub-mucous or peri-rec- tal abscess into the rectum should be suspected. The continuance of a purulent discharge off and on for a pe- riod of weeks and months, means the existence of a blind internal fistula. Diagnosis. With the patient either in the lithotomy or lateral position, a roughened spot with indurated edges is felt on digital examination, usually posteriorly or lat- erally. Upon stroking or milking the interior of the rec- tum adjacent to this opening, a purulent discharge will be produced. Upon examination through the anoscope or fenestrated speculum the opening will be seen usually within the first inch from the anal margin. It will be dark red in color, with edges somewhat raised and the extent of the fistula can be readily determined by exam- ination with a soft silver probe. It is well to bend the probe on itself in the form of a hook, so as to determine the extent of excavation under the mucous membrane of the bowel in the direction of the anus, as not infrequently blind internal abscesses, particularly of the submucous variety, are found with their largest cavity extending down towards the anus. The blind internal fistula is more frequently the result of a submucous abscess than of any other variety, and its channel very rarely penetrates the muscular coat of the rectum. Treatment. With the patient either in the lithotomy or lateral position and the external parts washed, shaved and sterilized, the sphincter ani muscle is anesthetized and dilated according to the technique described in Chap- ter XV. Either a De Vilbiss rectal speculum or the ano- scope with the opening on the slant is inserted so as to best expose the opening of the fistula. Its direction and 168 BLIND INTERNAL FISTULA SUBMUCOUS TRACT. extent having been determined, the tissues over the ab- scess and surrounding it are infiltrated with one-tenth of one per cent solution of eucain. A grooved director is then inserted and the fistula is laid open with a long- handled scalpel or the author's angular rectal scissors. A pledget of absorbent cotton soaked with 4% solution of eucain is then placed in the abscess cavity and allowed to remain for two or three minutes. The interior of the tract is lightly curetted and a strip of sterile gauze in- serted for drainage, one end of the gauze being carried outside of the anus. In laying the tract open, the lower extremity should be opened well down to the anus, care being taken to leave no pockets at the lower epd. In 24 hours the gauze is removed and a cleansing enema given. The bowel should be allowed to move on the third day, the stools being softened by the administration of liquid albolene, and they should be kept moving regularly each day. Ordinarily these cases will heal without any fur- ther attention. It is well, however, to have the patient report every other day for a week or so and to make sure that the cavity is kept healing from the bottom and the granulations healthy. Submucous Tract. There is a variety of submucous fistula extending usually from the bottom of a crypt of Morgagni which has been called by Wallis. a submu- cous tract. It consists in nothing more or less than either an unusually small calibered submucous fistula, or a very deep inflamed crypt. It gives rise to an irritating puru- lent discharge which is very small in amount, but which sometimes is responsible for the production of pruritus ani. In order to determine its presence, it is advisable in those cases where a discharge is noted and no internal SUBMUCOUS FISTULA BISMUTH PASTE. 169 opening of a blind fistula can be found, to examine with a probe each of the Morgagnian crypts and determine the presence or absence of one of these so-called submucous tracts. If present, it can be slit up with a sharp pointed bistoury- after anesthetizing as outlined above. It re- quires no after-treatment other than examination every other day for three or four days, to make sure that it does not heal over at the surface before it is thoroughly healed underneath. Submucous or Muco- Cutaneous Fistula. Cripps de- scribes a variety of fistula very similar to the submucous tract which he calls muco-cutaneous fistula. It differs from the variety just described only from the fact that it communicates with the surface through a small open-, ing in one of the anal folds instead of one of the crypts of Morgagni. (Fig. 71,4.) The treatment of this variety is just the same as that just preceding and need not be described in detail. The Injection of Bismuth Paste. The use of a mix- ture of bismuth subnitrate and vaseline in the diagnosis and treatment of fistulous tracts, sinuses and abscess cavities, first brought out by Emil G. Beck, of Chicago, has opened up an interesting field in the non-operative treatment of ano-rectal fistulae. Pennington, in a recent article on the subject in the Lancet-Clinic, December 26, 1908, reports 17 cases treated by this method. The paste used by Pennington consisted of bismuth subnitrate 1 part and vaseline 2 parts. To stiffen the paste from 5 to 10 % each of white wax and soft paraffine are added. The technique is as follows: The patient's bowels are thoroughly washed out and the fistulous tract irrigated as well as possible. An olive 170 INJECTION OF BISMUTH PASTE. * pointed glass syringe with asbestos packing around the plunger is filled with the mixture, which has previously been sterilized and allowed to cool to a temperature that will not irritate the patient. The point of the springe is pressed well into the main opening of the fistula, if more than one exists, and the paste slowly injected. Should there be an internal opening or communication with the bowel, the finger of the hand not manipulating the syringe is inserted into the rectum to close that opening, thus pre- venting the paste entering the bowel and aiding in forc- ing it into all the diverticuli and tortuous tracts. The same precaution is observed where there is more than one external communicating opening. The syringe is not removed as soon as the tracts seem to be filled, but is held firmly in position with slight continuous pressure on the piston. The finger in the rectum is also held in position until the material has hardened, when it may be with- drawn and the syringe removed. A gauze dressing and T-bandage are then applied. From one to five injections suffice for the average case, and they should be given ei- ther once or twice a week. Pennington's cases required from 2 to 6 weeks for a cure. While he states that this method does not supplant the radical cure of fistula by operation he feels that it should be thoroughly tried in all cases before operative procedures are undertaken, for these reasons : 1. It may cure the case. 2. On account of the aversion of most patients to a surgical operation. 3. On account of the failure now and then of the occasional operator to cure his patient. 4. On account of the fear of the loss of control over the bowels. 5. For its cosmetic effect, there being no scars or irregularities left as after surgi- FISTULA I]ST ANO IN THE TUBERCULOUS. 171 cal operations. 6. Because it is often impossible to tell the extent of the fistula until after the operation is begun. 7. If this method should fail, there always remains the various surgical procedures. Fistula in Ano in the Tuberculous Patient. The only reason that the discussion of fistula in ano in a tubercu- lous patient is taken up among these varieties of fistula which can be treated under local anesthesia, is the fact that the tuberculous patient is a very poor subject for general anesthesia. The apparent connection between fistula in ano and tuberculosis is due to the fact of the tubercular patient's resisting powers being away below par. Abscesses in the ano-rectal region tend to fistula formation frequently enough in those individuals who have a normal resisting power; therefore it stands to reason that this should be more so in those suffering from any of the wasting diseases and particularly the most common one, tuberculosis. The tubercular patient's in- testinal tract is constantly flooded with tubercular bacilli and an abscess cavity communicating with the gut forms a convenient location for them to locate and propagate. The old idea that the operation for tuberculous fistula has any bad influence on the patient's pulmonary condition is absolutely untenable. As a matter of fact, the local symptoms and inconvenience caused by the fistula make the patient much more irritable and adds to his already overwhelming burden. Symptoms. The symptoms are those accompanying fistula in ano as described above, the constitutional symp- toms of tuberculosis being also present. Diagnosis. The only point of difference between fist- ula in ano complicated with tuberculosis and ordinary 12 172 TUBERCULOUS FISTULA TREATMENT. fistula is the presence in the discharge of the bacillus tu- berculosis, and the pink, flabby looking, unhealthy, granu- lations found around the external opening. There is also a tendency to undermining of the skin edges. Treatment. The treatment of a tuberculous fistula is the same as that outlined above for the different van eties of ordinary fistula in ano, with the exception that when the fistulous tract is laid open after lightly curet- ting, its inner surface is swabbed with pure lactic or gla- cial acetic acid. lodoform or iodosyl gauze is used for packing and dressing on account of the peculiarly antag- onistic effect of iodine to the tubercle bacillus. The pa- tient should be encouraged to live an out of door life, and his general bodily nutrition and physical condition looked after the same as any other tubercular patient. CHAPTER X. HEMORRHOIDS. Hemorrhoids, which is the most common disease of the ano-rectal region presenting a pathological change in the tissues, is also the most frequently self-treated condition affecting this region. We see more quack advertisements, more nostrum remedies presented for, more irregular practitioners holding themselves out to cure hemorrhoids, than any other disease (with the possible exception of venereal disease). In many quarters intelligent people, who would not think of consulting an unethical practi- tioner for any other condition, will consult the so-called "pile specialist" who holds himself forth in the daily press because they believe that members of the regular profession do not treat rectal diseases. It is perfectly astonishing to what an extent this belief is held; in fact, the author is sorry to say that he knows of instances where members of our profession, in good standing, have referred cases of rectal disease to advertising, so-called rectal specialists. There must be a reason for this, and that reason is the lack of instruction to the medical student on the subject of rectal disease, in the first place; the paucity of such instruction when given as an incident in the teaching of general surgery; the repugnance with which the average 173 174 NEGLECT OF PROCTOLOGY BY GENERAL PROFESSION. practitioner approaches a case requiring rectal examina- tion; the cursory character of such examination; the dis- taste of the average practitioner for local treatment of the ano-rectal region ; the inability to make a correct diag- nosis; and the superficial treatment given and the early discharge of the patient by the practitioner, who is anx- ious to get rid of a case, which is unpleasant for him to treat all are responsible for the position which the av- erage general practitioner occupies today in the diag- nosis and treatment of rectal diseases. It is the action of the profession itself which has cre- ated the special field of proctology the anus and rectum being organs peculiar to themselves and being subject to many medical and surgical diseases in the same way as the eye, the ear, the nose, the genital and urinary organs ; and call for just as much special medical as for surgical care. The general surgeon knows nothing about, and cares less for, the medical treatment of these organs ; and the general practitioner who is able to treat the medical conditions is not, as a rule, properly equipped to do so. Thus, the proctologist came into existence- a man who, by special study of this particular region of the body, is able to give special care of either a surgical or medical nature, and often both in the same case, as may be required. With his attention directed particularly to this line of work, his operative measures are directed largely along the lines of conservatism. He endeavors to save as much tissue as he can and cut as little as he can, and by intelligent after-care to promote healing much more near the normal as a rule than does the man who "cuts a fistula and ties a pile" and lets it go at that. That the average general practitioner is fully as capa- HEMORRHOIDS CLASSIFICATION. 175 ble to treat many ano-rectal diseases, as the proctologist ; if he has at his hand a practical work outlining indicated therapeutic measures in a plain, simple way; goes with- out saying. The treatment of hemorrhoids in the hands of the prac- titioner has undergone vast changes since special atten- tion has been directed along this line. In many ways it has been much simplified, and the results have been ex- tremely satisfactory. Varieties. Hemorrhoids are tumors or swellings pro- duced by pathologic changes in the veins of the anus and rectum, accompanied by more or less infiltration of the surrounding tissues and hypertrophy of the anal skin. They are usually divided into three classes, according to location: External, internal, and externo-internal. The external being those outside of the sphincterial region and covered by integument; the internal being covered with mucous membrane, and whether situated inside of the bowel or prolapsed outside ; they are nevertheless inter- nal. An internal hemorrhoid being prolapsed and remain- ing prolapsed may appear externally, but if it is covered by mucous membrane it is an internal hemorrhoid. The externo-internal variety is a combination of the two pre- ceding, being covered by both mucous membrane and skin. The external, again, are divided into thrombotic, integu- mentary and varicose. The thrombotic variety usually appears suddenly ; may range in size from a pea to a large grape ; is rounded, of a bluish, purplish hue, and extremely painful. It feels much larger to the patient than it really is, and is charac- terized by its sudden onset. The integumentary variety is a sac or pouch of thickened skin, usually the remains of 176 HEMOERHOIDS CLASSIFICATION. . Fig. 79. Acute External Thrombotic Hemorrhoid. These are characterized by their sudden onset and are of a bluish or purplish hue. Drawing from photograph of one of author's cases. an old acute thrombofic hemorrhoid which has undergone absorption. The varicose variety consists of a collection of small varicose veins covered by skin and- situated at or outside of the anal orifice. The internal variety are divided into the capil- lary or granular, and the varicose. The capillary hemorrhoid may not appear as a tumor at all, but simply a circumscribed reddened area which bleeds upon touch. Where there is an enlargement, it HEMOKRHOIDS ETIOLOGY. 177 looks not unlike a raspberry. Its color is brighter than the varicose variety and it bleeds more freely. The vari- cose internal hemorrhoid is caused by a varicosity of the veins of the superior hemorrhoidal plexus, the varicose veins, together with the infiltrated skin surrounding them, forming rounded tumors of varying sizes. The internal hemorrhoids may also be divided into pedicled and ses- sile, either of which variety may protrude through the anus. Fig. 80. External Thrombotic Hemorrhoids. This specimen, removed from one of the author's cases, illustrates the thrombotic nature of the condition. There were four distinct clots present in this case, and they were removed en masse. Causes. A great many different causes have been as- signed for hemorrhoids. The principal predisposing cause is the erect position which man assumes, and the lack of valves in the rectal veins, causing the weight of the column of blood to rest on the veins of the lower rectum and anus. Anything which will abnormally increase this weight or the pressure on the vein wall will, of course, 178 ETIOLOGY. Fig. 81. External Cutaneous Hemorrhoids. Drawn from one of the author's cases suffering from tertiary syphilis. cause dilatation and enlargement. Constipation is an occasional cause of hemorrhoids. The large, hard stool, as it is passed down through the rectum, pushing the blood ahead of it, and milking the veins, as it were, caus- ing unusual pressure in the lower portions 'of the hemor- rhoidal plexus at the anal canal. A more common cause, however, than constipation is the effort to relieve consti- pation by means of purgatives; the unnatural straining and the irritating liquid stools being responsible for more cases of hemorrhoids than constipation itself. Over-eat- ing and lack of exercise, or anything which causes a con- ETIOLOGY. 179 gestion of the portal circulation are important causative factors in their production. Occupation enters largely into their etiology. Men who are on their feet continu- ally, such as policemen, letter-carriers, pedestrians, rail- road men, travelling men are all peculiarly subject to hemorrhoids. Men are more often treated for hemor- rhoids than women, not so much because they are more subject to hemorrhoids, but because women are treated for many gynecological conditions, the relief of which relieves the hemorrhoids. Many women who suffer from hemorrhoids caused by the pressure of the pregnant uterus will be spontaneously cured after delivery. Fig. 82. Interne-External Hemorrhoids. Drawn from one of author's cases. 180 HEMORRHOIDS SYMPTOMS. The most common cause, however, is in the opinion of the writer, the abuse of the cathartic habit. Symptoms. The three principal symptoms associ- ated with internal hemorrhoids are bleeding, pain and prolapse. The bleeding is of especial interest. Many patients suffering from hemorrhoids scarcely ever, if at all, pre- sent the symptom of hemorrhage. In those cases the mu- cous membrane covering the hemorrhoid (and we are speaking of the internal hemorrhoid at this time) is thick and is not easily ruptured, and the hemorrhoids may pro- Fig. 83. Section of Interne-External Pile. (Photo-micrograph, X4.) Upon the right hand side of the illustration the upper half has a cov- ering of mucous membrane, the lower half a covering of skin, between these there is a sulcus which corresponds with the pectinate line. The upper half is therefore internal pile, the lower, external pile. The structure of the interior of both portions is practically identical loose areolar tissue with dilated thrombosed veins. The Rectum: Its Diseases and Developmental Defects. By Sir Charles Ball. THE SYMPTOM, BLEEDING. 181 trude without hemorrhage. Where bleeding is observed, it may be very slight, consisting of a few drops following the stool, or is simply noticed on the toilet paper after stool. In other cases it is very profuse, several ounces being lost with each stool, and some patients have become profoundly anemic from this cause alone. I might men- tion in passing that it is extremely important in every case of anemia to inquire as to whether the patient is suffering from hemorrhoids or not; as not infrequently the rectal hemorrhage will be found to be the cause of the trouble, and its relief will be followed by a prompt return of the normal amount and quality of blood. The writer has observed in anoscopic examination typical nr- terial spurting from the midst of a hemorrhoidal mass. Before leaving the subject of bleeding from hemor- rhoids the author wishes to utter a word of caution about making a diagnosis of hemorrhoids from the symptom of rectal hemorrhage alone. Many a poor unfortunate has gone to an untimely end because commencing malignant disease was erroneously diagnosed as hemorrhoids be- cause of the symptom of bleeding alone. It makes no dif- ference as to the age of the patient, or whether there is pain present or absent, the symptom of hemorrhage should never be taken for granted as denoting the pres- ence of hemorrhoids ; and even where hemorrhoids are ob- served, no man should be satisfied that he has made a correct diagnosis until he has made a proctoscopic exami- nation (which must include the upper rectum and sig- moid) and the presence of commencing malignant disease has been absolutely excluded. It is not the intention of the author in this work to cite cases, but he could cite several seen in consultation 182 THE SYMPTOM, PAIN. Fig. 84. Interne-External Hemorrhoid Injected With Anesthetic Solution Ready to Operate. where the diagnosis of malignant disease was made too late to save the patient's life, because the patient had been allowed to go for monthsbeing treated for hemorrhoids without ever having had a rectal examination made. He has also seen numerous cases of fissure-in-ano diagnosed as hemorrhoids simply from the appearance of blood fol- lowing stool. The pain of internal hemorrhoids is somewhat charac- teristic, but not pathognomonic. It is more a dull aching sensation accompanied by a feeling of fullness with or without throbbing. It is seldom of an acute nature. The patient complains of a constant sense of weight and drag- ging in the rectum and in the sacral region, and is usually more or less mentally depressed. Many patients having hemorrhoids suffer from no pains whatever. The pain accompanying the acute thrombotic pile is THE SYMPTOM, PAIN. 183 sudden, lancinating in character, and is accompanied by the appearance of the tumor. The pain soon becomes of an intense, throbbing character, and the relief given upon the incision of the hemorrhoid and removal of the clot, has to be seen or experienced to be appreciated. The other varieties of external hemorrhoids are not accompanied by pain at all, but may be accompanied by considerable pru- ritus. Fig. 85. Prolapsing Internal Hemorrhoids. Drawn from a photograph of one of the author's cases. This illustrates the extent to which internal hemorrhoids may pro- lapse. This case was of 20 years' standing and unless the hemorrhoids were prolapsed after stool there was nothing to distinguish the external appearance of the anus in this case from the normal. A case of this severity would of course be suitable for treatment only under general anesthesia. 184 HEMORRHOIDS DIAGNOSIS. In those cases of internal hemorrhoids which prolapse, the prolapse is slight at first, gradually increasing with time. At first the prolapse is replaced readily by the pa- tient after stool, but as time goes on and the prolapse be- comes aggravated, it will come down not only with the stool but when the patient is up and about and walking. It finally remains down and can only be replaced when the patient is lying down, or in the knee-shoulder position, and even when held by pads or retaining devices soon slips out again, when the patient resumes the erect pos- ture and starts to walk. Diagnosis. One would think that the mention of the diagnosis of hemorrhoids would be superfluous, and that the condition almost diagnoses itself ; but it is because of the many unfortunate erroneous diagnoses of other con- ditions for hemorrhoids, that the author wishes to dwell somewhat upon this point. In the first place, the average patient, when consulting a physician for suspected hemorrhoidal or other rectal troubles, is asked to stand in front of a table (see Fig. 15) and bend over on it for a ''rectal examination," and the physician inserts his index finger as far as the patient will allow him, and that is all ; or, he may take a bivalve rectal speculum (Fig. 35), and, if he succeeds in inserting it far enough, will proceed to dilate. Usually before he has gone very far, the patient is off the table and refuses to allow a repetition of the attempt, and that is about as far as the average rectal examination goes. Now a complete examination (see Chapter III) of not only the rectum, but the lower sigmoidal cavity as well, may be accomplished, practically without pain, and with- out any dilating speculum. Cylindrical proctoscopes of BECTAL EXAMINATION. 185 various lengths are used, and through them everything from the anal orifice to the lower sigmoidal cavity can be examined ocularly and an absolutely correct view of the actual condition obtained. In making an examination for hemorrhoids, first ask your patient to lie upon the table in either the right or left Sim's position according to the personal preference of the examiner. "With the finger protected by a thin rub- ber finger cot, and properly lubricated, you proceed as follows : After making a careful inspection of the anus and sur- rounding tissues, press the point of the finger against the anus, asking the patient to gently bear down as if he were trying to force the finger out. The palmar surface of the finger should be towards the posterior commissure of the anus. Allow the finger to slowly enter until you have entered the lower rectal cavity ; then, slowly turning your finger from side to side, note the conditions. As the finger is being withdrawn, it should be swept around slowly, taking note of the absence or presence of protru- sions or abrasions, depressions, elevations in fact every- thing which does not feel like the normal velvety smooth- ness of the anal canal. An important thing to remember is not to try to feel too high. These conditions will all be found within the first two or two and one-half inches, and if one does not insert the finger too far, he will be able to detect a great many things in this small area. One must remember that hemorrhoids of considerable size may not present any unusual feeling to the examining finger, because of the pressure of the finger emptying them of blood, and they are more or less effaced at the time. However, one can become sufficiently expert, so ]86 RECTAL EXAMINATION. that he can detect the presence of even these soft eleva- tions, and will note the furrows between them. If the presence of hemorrhoids is accompanied by a painful fissure, one may not be able to insert the finger without the use of a local anesthetic; the technique of which will be found in Chapter XV. After digital exami nation has been completed, an anoscope is introduced, the obturator withdrawn, and the patient asked to bear down. This will prolapse hemorrhoids into the instru- ment, where they can be examined without any difficulty, or have the patient assume the squatting position and "strain" the hemorrhoids out. Then introduce the proc- toscope, and following this the sigmoidoscope. In intro- ducing the proctoscope, however, one must employ the knee-shoulder position. It is in this position only, that satisfactory dilatation of the rectal cavity by pressure of the atmospheric air can be obtained. The folds and creases are all smoothed out and every portion of the rec- tal lining mucous membrane can be explored with the eye ; the size and condition of the rectal valves can be de- termined, and the presence or absence of ulcers of the rectal wall as well. The sigmoidoscope is entered in this position or the exaggerated lithotomy position, and hav- ing an obturator the end of which can be turned at an angle, it can enter the recto-sigmoidal curve without dif- ficulty. Thus it will be seen that this entire region can be suc- cessfully and completely examined without using an in- strument which will dilate the sphincter any more than the base of one's index finger. No dilatation is re- quired and no pain is experienced by the patient. Of course, during the examination it may be required to DIFFERENTIAL, DIAGNOSIS. 187 swab out or douche out the rectum, all of which can be readily done through the instruments mentioned. In the differential diagnosis between hemorrhoids and other conditions, which may-simulate some of their symp- toms, one might mention first, fissure. Fissure of the anus, which may accompany hemorrhoids, is more often found alone. The pain of fissure is almost diagnostic ; it is sharp, cutting, most intense during the passage of a stool. It remains often for several hours following stool, and is accompanied by more or less tenesmus and spasm of the sphincter muscle. The bleeding of fissure always accompanies or follows the stool. It may consist merely of a blood streak on the stool or several drops of blood following the stool, or it may merely be a spot or smear on the toilet paper. The presence of a fissure causes the pa- tient to put off the bowel movement as long as possible, and when he does defecate, the hard fecal masses cause more pain and discomfort than before. Digital examina- tion reveals a fissure with more or less indurated sur- rounding tissue situated most often at the posterior com- missure, or in either the right or left latero-posterior quadrants. Ulcer of the rectum may be incorrectly diagnosed as hemorrhoids, on account of more or less slight hemor- rhage which may accompany it. Ulcer, however, is usu- ally accompanied by diarrhoea; and ocular examination, after eliciting a history of blood in the stool, will settle the diagnosis at once. The same may be said of proctitis ; an intensely congested and injected rectal mucous mem- brane may bleed on stool, but if the conscientious practi- tioner examines every patient who presents the symptom of blood in the stool, many sources of hemorrhage other 13 188 DIFFERENTIAL DIAGNOSIS. than piles will be detected and the correct diagnosis made. Of course the one important thing always to bear in mind when the symptom of hemorrhage is present, is the possibility of the presence of cancer. Cancer, well ad vanced, may be found in patients who present the appear- ances of perfect health. When a patient of any age, from childhood up (just as often below 40 as above), pre- sents a history of rectal hemorrhage, which has been pre- ceded by more or less digestive disturbance, including diarrhoea alternating with constipation of several weeks or months standing, with considerable intestinal gas even though there is no evidence of cachexia or loss of weight; one should be extremely suspicious of malig- nancy somewhere in the intestinal tract. If the blood is of a dark color, either of a tarry nature or genuine coffee ground, the location of the cancer is higher up. If the blood is fresh, bright red in color and closely follows the stool, and has a more or less nauseating odor accompany- ing it (an odor which is almost pathognomonic) ; one should examine very carefully for commencing cancer in the rectum or sigmoid. When one considers that fifty per cent of all cancers occur in the gastro-intestinal tract, and when one realizes that sixteen per cent of all cancers of the digestive tract occur in the rectum or sigmoid, one can readily understand how important it is to examine every case which presents the symptom of rectal hemor- rhage. Various protrusions may be mistakenly diagnosed for hemorrhoids. Polypi, which may occur at any age, but oc- cur more often in children, protrude with the stool. They are harder, more fibrous in character than hemorrhoids, and when replaced by the finger, go back into the rectum DIFFEKENTIAL, DIAGNOSIS. 189 with more or less of a snap, which is somewhat character- istic of this condition. Anoscopic examination shows the polypus to be a small, rounded, hard, fibrous tumor, at- tached by a pedicle narrower than itself; its attachment being somewhat higher in the lower rectal cavity than that of a hemorrhoid. Enlarged rectal papillae have been diag- nosed as connective tissue piles. The enlarged papilla, however, is small, always triangular, and occasionally long drawn out and somewhat ribbon shaped. It is pink- ish in color; does not contain varicose veins. The point or tip is always downward, and it is attached by its base or widest portion. They are situated at the juncture of the anus and rectum, at the lower edges of the crypts of Morgagni. Venereal warts of large size have been incorrectly diagnosed as external integumentary piles, but close in- spection after obtaining a history of discharge from vene- real disease, should make the diagnosis evident. Occa- sionally the protrusion of an anal or peri-anal abscess may simulate an inflamed external hemorrhoid. However, with the finger of one hand in the rectum and the other hand on the protrusion, the site of the abscess cavity can be made out and fluctuation often determined. The sud- den onset, accompanied by the intense pain, swelling, red- ness and rise of temperature always point to abscess formation rather than hemorrhoid. The protrusion which is often diagnosed as prolapsed hemorrhoids is prolapsus ani or recti. There are three degrees of prolapsus : 1. Simple eversion of the anal mu- cous membrane. 2. The descent outside of the rectum of more or less of all coats of the rectum. 3. The descent of the entire rectum with more or less of the sigmoid, which 1 90 TREATMENT PALLIATIVE. may come down to the anal orifice but not necessarily protrude. Prolapsed mucous membrane is differentiated from prolapsed hemorrhoids by its smooth, velvety touch, reddish color, and the absence of varicose veins. It is continuous with the rectal mucous membrane and a dis- tinct sulcus can be made out between the anus and' the protrusion in the second and third varieties. In the first variety, careful examination will show it to be mucous membrane continuous with the anal skin. Of course in aggravated cases of prolapsed hemorrhoids more or less prolapsus of the mucous membrane of the anus will ac- company it, and the diagnosis is self-evident. Treatment. The treatment of hemorrhoids we will divide into palliative and radical. The palliative treatment of hemorrhoids is, however, not a cure, but a relief of acute symptoms for a more or less short period of time. When a patient presents him- self suffering from acute prolapsed internal hemorrhoids with more or less strangulation by a reflexly contracted sphincter, the first thing to do is to reduce the prolapse. This is not always as easy as it seems. The reflex con- traction of the sphincter on the hemorrhoids shuts off the return blood supply and the hemorrhoid swells so much that it cannot be replaced without anesthesia. If, how- ever, a solution of adrenalin chloride (1-1000) or gly- cerine be applied by means of compresses, the blood ves- sels will shrink to such an extent that reduction is often easy. Sometimes the application of cold or alum solu- tions will cause sufficient shrinking to make reduction easy. Chloretone, one-half of one per cent, or eucaine one to four per cent may be added to these solutions to render them anesthetic. Occasionally applications of CAUTERIZATION INJECTION METHOD. . 191 fluid extract of ergot will help in maintaining the con- traction of the vessels after adrenalin has brought them down. An ointment containing adrenalin, one to one thousand, chloretone 20 grains to the ounce in lanolin, injected into the anus after stool and three or four times a day, at regular intervals through a long nozzled collap- sible tube ; will often assist in allaying an acute attack of hemorrhoids. However, all of these treatments are mert*> ly palliative, and the hemorrhoid upon the slightest irri- tation, will enlarge, prolapse and even strangulate again. Some patients who absolutely refuse more ^radical measures will submit to cauterization of the hemorrhoid by the thermo-cautery, thus causing a deposition of scar tissue on the surface of the hemorrhoid which by its con- traction somewhat lessens its size, and repeated applica- tions of the cautery will reduce the hemorrhoid so that it will not be noticeable for some time. Occasionally such irritants as glacial acetic acid, chromic acid, and 100 per cent solution of nitrate of silver, have been used for i like purpose. The puncture of the hemorrhoidal mass in various places by means of the electric needle, as advo- cated by Kelsey, has been of some assistance in reducing the size of internal hemorrhoids, but never entirely re- moves them. The "injection treatment," which is the treatment usu- ally advocated by most of the irregulars, may be applied in a number of ways. The patient's rectum is cleansed by means of a simple enema, followed by one of the satu- rated solution of boric acid or some other antiseptic. The hemorrhoid, which should be of the prolapsing variety and one that can be easily extruded into the ano scope, or outside, is injected down to its base with either a mild 192 THE INJECTION TREATMENT. solution containing carbolic acid up to five or ten per cent, if one wishes to cause a mild inflammation and gradual occlusion of the blood vessels by the deposition of fibrous tissue ; or by a strong solution of carbolic acid running from 20 per cent to 50 per cent, when one wishes an immediate slough of the hemorrhoidal mass. When one has but one or two, or not to exceed four, prolapsing hemorrhoids, this method may be applicable, each hemorrhoid being injected at the time. In some cases two or three injections are necessary for each hem- orrhoid at intervals of five or six days, but on account of the danger of injecting a blood vessel, and on account of the inability to limit the slough caused by carbolic acid, it is rather an unsafe method, and repeated instances of destruction of large areas of tissue, and sepsis, have been reported. A rather ingenious method of applying the injection treatment has been advocated by Franck of Berlin. He employs a 50 per cent solution of carbolic acid in alco- hol, and uses it as follows : The hemorrhoid is rendered tense by the application of a wire snare around its base ; this is gradually tightened so as to cause the tumor to be slowly congested ; the needle is then planted in the cen- ter of the mass and several drops of the solution slowly injected. The snare is not removed until the whole mass has undergone thrombosis. Each time it is treated in a like manner and a dressing of some drying powder is applied. In seven or eight days the necrotic tissue will slough off and the granulating surface will be healed in three or four weeks. This long period of granulation is another objection to the application of the injection method. With the intro- OPERATIVE TREATMENT. 193 dtiction of local anesthesia in the radical treatment of rec- tal disease, the field for the injection method has been greatly encroached upon. It seems to the author much more rational to remove the hemorrhoid by a clean cut surgical incision, under local anesthesia, and have the pa- tient up and about on the second day, and the wound healed in from a week to ten days (this under local anes- thesia in office practice), than to use the uncertain, un- scientific injection methods. Therefore, the author will confine himself in this chapter to a description of the va- rious methods of operating on hemorrhoids under local anesthesia, as applicable in office practice. Operative Treatment Under Local Anesthesia. The technique of producing local anesthesia is, briefly, as fol- lows (see Chap. XV.) : Your patient, who has previously had a cleansing and antiseptic enema, is placed upon the table in the Sim's position. A large glass hypodermic syringe is filled with the solution of choice which may be cocaine, eucaine. aly- pin, chloretone or simple sterilized water, as the case may demand. Beta eucaine lactate, any strength varying from one-half to one-tenth of one per cent, is used for anes- thetizing the sphincter and is injected in this wise : After sterilizing the parts, a point one-half inch below and pos- terior to the posterior commissure of the anus is selected. A spray of ethyl chloride or a drop of pure carbolic acid is used to deaden the pain which accompanies the intro- duction of the needle. With one index finger in the anus, hooking down the sphincter, the needle in the other hand is passed inward, upward and laterally, in a V-shaped di- rection for about three-fourths of an inch, going down into the sphincter muscle, but not through it. From ten 194 LOCAL ANESTHESIA. drops to a drachm of the solution is slowly injected and the needle is retracted to the point of puncture, but not withdrawn ; then it is pushed up on the other side in the same manner, keeping about one-half inch away from the anal aperture. Then three or four minutes are allowed to pass to give the anesthetic time to take effect. Then a vibrator, armed with a cone-shaped vibratode, well lubricated, is pressed against the anus. About three minutes of rapid vibra- tion will dilate the sphincter painlessly to a sufficient cali- ber to allow the operation to proceed without difficulty. In the absence of the vibrator, one may use the index fingers of both hands, protected by finger cots, and by a gentle massage movement gradually accomplish the same object in a slightly longer period of time. When the sphincter is dilated, the hemorrhoid is in- jected, from its base to its apex, with plain sterilized wa- ter, or an extremely mild anesthetic solution, such as one- tenth of one per cent of eucaine lactate. The particular point to remember is that distension must be carried until the tissues are blanched and the hemorrhoid is in appear- ance not unlike a Malaga grape. I very seldom find it necessary to ligate any vessels, as their retraction very soon causes the hemorrhage to cease. The operation is then proceeded with according to the technique outlined below. A suppository containing three grains of thymol iodide, two grains of chloretone and two grains of powdered opium is inserted and a dressing applied, but the patient is not allowed to get up from the table for about ten minutes ; then is asked to rise slowly and either sit down or lie down as he wishes. I have found that when a pa- EXCISION TECHNIQUE. 195 tient is allowed to get up immediately, some dizziness or faintness is complained of, and I formerly attributed it to the chemical anesthetics injected, until I found that it also occurred in those patients in whom sterile water alone was used as an anesthetic. Fig. 86. Method of Injecting Prolapsing Pedunculated Internal Hemorrhoids. Excision. The hemorrhoid having a pedicle is injected at its base with sterile water or weak eucain solution the distension carried to blanching of the tissues, the base transfixed with a double threaded needle (linen suture being used), and the ligature double tied. The hemorrhoid is then cut off, leaving a sufficient stump to prevent slip- ping of the ligature. Each one is treated in like manner, a suppository of the composition mentioned above inserted, the bowels kept locked up for from three to five days, and 196 EXCISION TECHNIQUE. the patient allowed to be up and around after the first twenty-four hours. The patient is sent home usually in a carriage (occasionally they will walk or take the car), and is advised to lie on either one side or the other for twenty-four hours and then resume his occupation. It is surprising with how little discomfort they are able to get around and how quickly they recover. Fig. 87. Author's Hemorrhoidal Forceps. Provided with a "Battle Axe" shaped extremity, whose edge is serrated, instead of toothed. In the author's bloodless operation for hemorrhoids this is a very useful instrument ,for grasping the tumor without puncturing or lacer- ating it. The hemorrhoid which is sessile or non-pedunculated, is distended in the same manner as above. The most depend- ent portion is grasped with the author's pile forceps (Fig. 87) or toothed forceps; it is dissected up from its base with either knife or scissors to healthy tissue, care being taken to include in the dissection the vessels which enter the hemorrhoid from above. The upper part of the flap is transfixed and tied off, as is the pedicle in the above va- riety, when the tumor is cut off with the scissors; others treated in like manner, and the after-treatment is the same as above. It is a very rare thing for the author to have hemorrhage severe enough to require ligation of the vessels. Where there is more or less oozing, a piece of rubber tubing, about four inches long and surrounded AUTHOR S BLOODLESS OPERATION. 197 by gauze, is inserted, and the pressure of the gauze against the raw surface very soon checks oozing. This is removed in anywhere from one to twenty-four hours. Author's Bloodless Operation. A somewhat simple method is the author's technique for the removal of cer- tain forms of internal hemorrhoids without the profuse hemorrhage with which this operation is usually associ- ated in the minds of most medical practitioners. From the observation that most patients suffering from hemor- rhoids of the itnernal variety are more or less anemic from the continued and constant loss of blood, as a result of their hemorrhoidal trouble, I decided to use a tech- nique which would minimize operative hemorrhage and Fig. 88. Rectal Retractor Modified from Sims' Speculum. conserve the patient's blood supply. With this aim in view, I have developed and have been using a very simple technique which I present below: 198 AUTHOR S BLOODLESS OPERATION. It is applicable under local as well as general anesthe- sia, and therefore can be used in those weak, run-down patients suffering from any of the wasting diseases, in whom the use of a general anesthetic would be inadvis- able, if not positively dangerous. The method is appli- cable to any variety of internal hemorrhoids and particu- larly to the pedunculated and prolapsing varieties. Tn- terno-external hemorrhoids can also be treated by this method. Very few instruments are required and in most cases, dilatation of the sphincters is not required. The technique under general anesthesia is much the same as under local anesthesia, and inasmuch as local anesthesia is a good deal safer and fully as satisfactory as general anesthesia for this work; the author will describe the operation as performed by him under local anesthesia. Fig. 89. Author's Blunt Pointed Ligature Carrier. This instrument is very useful in the author's bloodless operation for hemorrhoids, for passing the ligature under the blood vessels of the hem- orrhoid; its blunt extremity preventing the puncture or injury of the vessels. The instruments required are a rectal retractor (Fig. 88), or Sim's speculum; the author's blunt pointed AUTHOR S BLOODLESS OPERATION. 199 ligature carrier (Fig. 89), the author's pile forceps (Fig. 87), scalpel, sharp pointed scissors curved on the flat (Fig. 54), aseptic hypodermic syringe with sharp needle and sterile cat-gut. The patient is given one-fourth grain of morphine about twenty minutes be- fore the operation is performed; the bowels are washed out with a soap suds enema, followed by a boracic acid enema. He is then placed on the operating table in the Sim's lateral position; the skin around the anus is scrub- bed, shaved, and sterilized. The sphincters are then anes- thetized by the injection of 20 to 30 minims of one-half Fig. 90. Technique cf Author's Bloodless Operation for Internal Hemorrhoids. A. Method of inserting ligature carrier threaded with catgut. B. Showing ligature tied, thus constricting the blood vessels supplying the hemorrhoid. C. Removal of the hemorrhoidal mass without sacrificing the mucous membrane. 200 AUTHOR'S BLOODLESS OPERATION. of one per cent beta-eucain lactate solution which has been sterilized by boiling, according to the technique de- scribed above. When dilatation has been accomplished, the most de- pendent hemorrhoid is injected with one-tenth of one per cent solution of eucaine lactate or sterile water, and the distension carried until the tissues are blanched. Anes- thesia is then complete. The lower extremity of the hem- orrhoid is then grasped with the author's pile forceps and pulled down so that it is on the stretch. The blunt- pointed ligature carrier, threaded with No. 2 cat-gut, is passed in through the mucous membrane on one side, down to the base of the hemorrhoid and around to the opposite side, in such a manner as to include the upper half of the mucous membrane covering the pile, and the blood vessels underneath, but not encircling the entire hemorrhoid as in ligating a pedicle (Fig. 90- A). This ligature should be placed just at the juncture of the pile and the healthy mucous membrane of the rectum. It is then firmly tied (Fig. 90-B), and it will be found that the blood supply of the pile has been included in the ligature and shut off. The piles at either side are dealt with in like manner and lastly the upper ones. A suppository containing : Chloretone gr. ii Thymol iodide gr. ii Powdered opium gr. ii is inserted, the patient keeping in the recumbent position for ten minutes, and then allowed to rise from the table and go to his bed. There will be considerable swelling during the first 24 hours, but this with its accompanying AUTHOR S BLOODLESS OPERATION. 201 pain, can be relieved by the application of hourly com- presses soaked in the following solution : 1* Adrenalin chloride (1 to 1000) i/o ounce. Chloretone 30 grains. Glycerine 4 ounces. Water 4 ounces. This swelling subsides in from two to four days and the pile gradually shrinks until at the end of four weeks, there is nothing left but a little hard "nub" of connect- ive tissue which can be snipped off painlessly with the scissors at any time. This, which is the simplest form of technique, is applicable to those desperate cases of anemia where the continual loss of blood from the hemorrhoids is greater than the patient's blood production. It can be done in from ten to fifteen minutes' time, and involves the least expenditure of nerve endurance and suffering of the patient. In cases where the necessity for haste is not quite so imperative, I use the following modification of the technique: After the hemorrhoid is anesthetized as above, and the ligature applied in the same manner, the pile is grasped in the author's pile forceps and an incision made in its longtitudinal axis, starting about one-quarter of an inch from the ligature and extending down to its distal ex- tremity, then with the curved scissors, the blood vessels and connective tissue which make up the body of the pile, are dissected out en masse (Fig. 90-C) and cut off about one-quarter of an inch from the ligature. The wound is left open to heal by granulation, which it does in a very few days. This dispenses with the hemorrhoid at once 202 AUTHOR'S BLOODLESS OPERATION. and does away with the swelling, pain, and discomfort which necessarily follows the preceding technique. In cases where we have peduncnlated, prolapsing hem- orrhoids, it is not necessary to dilate the sphincter or use the speculum. Following an enema, the patient is asked to strain while in the squatting position or lying on his side, while the operator is everting and pressing back the sphincter muscles by pressure just outside of the outer margins of the external sphincters. The pile which is prolapsed by this method is injected with the weaker anesthetic solution. Its pedicle is transfixed with the blunt ligature carrier double threaded with cat-gut and tied off in two sections. The pile is then cut away one- quarter of an inch from the ligature, and the stump cau- terized with 95 per cent carbolic acid. The other pedun- culated hemorrhoids are treated in like manner, the anal- gestic supository inserted, and the operation is com- pleted. The after care is very simple, the bowels being con- fined for from three to five days. A drachm of compound licorice powder at night followed by a six to ten ounce oil enema in the morning, will produce an easy and satisfac- tory movement at the end of that time. A teaspoonful of liquid albolene before each meal will keep the bowels in good order and daily soft movements will follow. The only dressing required is some drying and protective powder such as compound stearate of zinc, which should be applied sufficiently often to keep the parts protected. Some of the many advantages of this method are as follows : SUBMUCOUS EXCISION. 203 1. The technique is simplicity itself. 2. It is applicable under local anesthesia. 3. It takes a shorter time than any other method which successfully disposes of the hemorrhoid. 4. It is surer, safer, and quicker than the "injection method," and is applicable in every case where the injec- tion method can be used, as well as in other varieties of hemorrhoids where the injection is contra-indicated. 5. It should be the method of choice in all patients suffering from anemia, tuberculosis, hemophilia, and in pregnancy ; because of all the foregoing reasons, and the fact that it doesn't involve the loss of blood. The prin- ciple of tying before cutting reduces the waste of blood to a minimum, and makes for rapid convalescence. 6. There being no confinement to bed after the first 24 hours, the patient may be up and about, going out of doors, getting fresh air, sunlight and exercise, which are nature's best curative agents in convalescence after any operation or disease, and of the greatest value to patients suffering from any of the wasting diseases mentioned above. Submucous Excision. In the sessile variety, an- other way of treating these is simply to make an incision in the longitudinal axis of the bowel through the center of the mass, and then by the use of the author's angular rectal scissors (Fig. 48) to macerate and de- stroy the blood vessels beneath the mucous membrane on either side of the incision. The blood supply being de- stroyed and the macerated tissue cleaned out with a curette, the wound is allowed to heal without suture, and usually does so in four or five days. Of course this method is accompained by some hemorrhage, but never severe 14 204 CONTRA-INDICATED METHODS. enough, however, to require ligature. The after-treat- ment is the same as in the other varieties. The clamp and cautery operation is not applicable, of course, under local anesthesia, and I mention it merely to condemn it. I do not believe that the use of a red-hot iron in a cavity lined with mucous membrane is rational, and while I am aware that many surgeons have used it with many successful results, I have seen strictures following its use which were caused by the overgrowth of scar tis- sue which is more prone to follow a burn than any other form of wound. A clean cut surgical incision, to my mind, is more rational and is not followed by the ex- tensive sloughing or the extensive cicatrix. Crushing the hemorrhoid with the angiotribe has also been used by some operators, and offers the objection that it destroys too much mucous membrane and is followed by a more or less chronic granulating surface taking weeks to heal. The Whitehead operation is, in the author's opinion, very seldom, if ever, indicated. Other methods of disposing of large redundant hemor- rhoidal masses by means of elliptical flaps, longitudinal incisions, and plastic work, are used to obviate the neces- sity of doing any operation, which is almost certain to be followed by sepsis, retraction of flaps and subsequent cicatricial contraction; and the writer has yet to see a case of hemorrhoids accompanied by prolapse, so severe that he has not been able to remedy it without sacrificing the normal contour of the anus. These last varieties have been mentioned simply because no chapter on the treat- ment of hemorrhoids will be complete without their re- cognition by some mention at least. ACUTE THROMBOTIC HEMORRHOIDS. 205 The acute thrombotic variety (Fig. 79) is peculiarly amenable to treatment under local anesthesia. On account of its sudden onset and the acute suffering which it pro- duces, the patient will present himself for treatment with- in a very few hours after its onset. Examination in the lateral position shows a rounded, bluish or purplish tu- mor varying in size from that of a pea to a large grape, located just at the anal margin usually on one side. It usually occurs singly. After the usual preparation, the hemorrhoid is injected from its outermost aspect with 10 or 12 drops of one-half of one per cent solution of eucain lactate the injection being carried just underneath the skin or mucous membrane, and not down into the pile. After allowing a minute or two for the anesthetic to take effect, an incision is made through the skin and down to the clot, parallel to the long axis of the anus and extend- ing for about a quarter of an inch into the skin beyond the tumor. The tissues around the tumor and below it are in- jected with one-tenth of one per cent solution of eucain, when it is dissected out by means of a small toothed for- cep and the scissors curved upon the flat. After the clot (Fig. 80) is removed, look carefully into the wound to see whether a second clot has formed below, and if so, it must be removed at the same time. The edges of the wound are trimmed back in an elliptical manner, so as to leave a gaping wound, which will heal by granulation from the bottom, without any possibility of the edges of the wound turning in and retarding its healing. A one- half inch strip of chloretonized tape or gauze is lightly inserted into the wound and a sterile dressing applied. This gauze is removed in 24 hours, when it will not be found necessary, as a general rule, to re-pack the wound. EXTERNAL HEMORRHOIDS. It should be seen and dressed daily, and some mild anti- septic powder applied such as thymol-iodide, boric acid, boro-chloretone, stearate of zinc, or acetanilid. The pa- tient after this operation, experiences a keen sense of relief almost from the start from the relief of the tension caused by the thrombotic mass. The removal of external hemorrhoids of the integumen- tary (Fig. 52) variety is very easily accomplished under local anesthesia. After the parts are prepared, shaved and sterilized with the patient placed in the left lateral or lith- otomy position, the most dependent pile is selected, the point of puncture touched with a drop of pure carbolic Fig. 91. Distension of External Hemorrhoids With Sterile Water. This photograph of one of the author's cases shows the amount of distension necessary to produce anesthesia with plain sterile water. This is taken from the same case as figure 52 and comparison of the two will be of interest. TREATMENT OF EXTERNAL HEMORRHOIDS. 207 acid or sprayed with ethyl chloride until the tissues are blanched, when the spray is removed, and as soon as they have regained their natural color the injection is made. As in all operations involving the skin, the first injection should be of one-half of one per cent solution of eucain lac- tate, care being taken to inject the first ten or fifteen drops just underneath the skin along the line of the proposed incision so as to form a wheal or welt. An incision is then made on a line radiating at right angles from the anal orifice to the distal extremity of the tumor, then the subcutaneous tissues are infiltrated with one-tenth of one per cent eucain solution or one-half of one per cent solu- tion of chloretone, or^ sterile water. The hemorrhoidal mass is then^eized with the author's hemorrhoidal for- cepts and removed with a flat pair of scissors. The skin edges are trimmed back on either side in the shape of an ellipse, so as to include all of the redundant tissue which forms the covering of the pile. One must be cautious about not cutting away too much skin. The distension with the anesthetic solution somewhat distorts and dis- tends the skin, and the infiltration extends beyond the part to be removed, making it appear much larger and ex- tensive than it in reality is (Fig. 91). It is a wise plan, therefore, to carefully mark out, before proceeding to op- erate, the extent of the proposed incision by means of a small swab moistened with tincture of iodine. Each hem- orrhoid is treated in like manner, working from below up- wards, and the wounds lightly packed with chloretonized gauze and the wound allowed to heal by granulation. There is no objection to putting a couple of silk-worm stitches in each wound, if desired, but the author has found healing fully as satisfactory without stitching and 208 AFTER-CARE. the time of the operation is materially lessened, which is an important factor in all work under local anesthesia. The after-care is similar to that outlined in the treat- ment of acute thrombotic hemorrhoids. The healing fol- lowing operation for external hemorrhoids should be complete in a week or ten days. During the healing process, the patient should be re- quired to use an infllated air cushion, or pillow, when sit- ting, and to lie upon either side rather than upon the back. As has been stated above in the treatment of inter- nal hemorrhoids, it is wise to put the patient upon a light diet, consisting of meat, broths and strained veget- able soups, with the addition of eggs or gelatins for the first three or four days. The bowels should be confined and not allowed to move until the fourth day, when, by means of a dose of licorice powder (one to three drachms) given the night before, and a ten ounce oil ene- ma, the bowels should be moved. The movements there- after should be kept soft by the administration of drachm doses of refined petroleum oil (liquid albolene), four or five times daily, and the diet gradually increased. After the first movement, daily evacuations of the bowels should be procured. Where, on account of the number and redundancy of external hemorrhoids, the operation for their removal under local anesthesia would be too extensive or involve too much time if attempted at one sitting, the work may be divided ; half being taken care of at one time, and the other half after an interval of two or more weeks. The author would not advise the removal of more than three or four external hemorrhoids at one operation. It is very rare, however, to find more than this number as a general rule. CHAPTER XL RECTAL POLtPI HYPERTROPHIED ANAL PAPILLAE CRYPTITIS. A polypus is a non-malignant tumor, whose chief char- acteristic is its attachment to the rectal wall by a pedicle, which is always narrower than the tumor (Fig. 92). It oc- curs more often in children than in adults. Polypi may be found singly or in such large numbers as to entirely fill the rectal cavity, and will be found complicating fissure in ano, hemorrhoids, prolapsus, and other rectal diseases. The usual location of a polypus is in the lower end of the rectal canal from one to two inches from the anal opening. 'Rarely cases have been seen in which the poly- pus has been found attached by a pedicle four or five inches long as high as the recto-sigmoidal juncture. The types of polypi most commonly met with are either the soft myxomatous or adenomatous variety, and the hard fibroid polypus. In appearance, the soft granular polypus resembles a raspberry, and bleeds readily at the touch. The fibroid variety is hard, rounded and lighter in color than the normal rectal mucous membrane. Symptoms. The usual symptoms outside of the appearance of the polypi itself, are the passage of blood, mucous, and straining efforts after stool ; the patient com- plaining of a feeling, as if more fecal matter were 209 210 POLYPUS DIAGNOSIS. rectum, but it was impossible to evacuate it. Diagnosis. The diagnosis is very simple, as they are often discovered protruding from the anus. A pecu- Fig. 92. Rectal Polypus. POLYPUS TREATMENT. 211 liar characteristic of polypi is the snapping sensation which they give to the finger as they are returned to the rectum. On making a digital examination, with the pa- tient in the lateral position, one should insert the finger as high as possible, and then sweep it from side to side, completely encircling the rectum on its withdrawal, when the polypi will be discovered, usually just above the inter- nal sphincter. As the finger is withdrawn, the polypi can often be brought with it, outside of the sphincter. By means of proctoscopic examination, polypi situated higher in the rectum may be discovered. Treatment. In the treatment of polypi, local anes- thesia is often not necessary. They can be snared off with ease through the anoscope or proctoscope with little or no pain. Where the polypus is situated low, so that it can be protruded through the anus, the pedicle may be infiltrated with one-tenth of one per cent solution of eucain or chloretone, transfixed with a double threaded needle, and the pedicle tied off in two sections with a double ligature. The polypus is then snipped off with the scissors, leaving as little stump as is possible. It is prac- tically never necessary to anesthetize the sphincter and no after-treatment is required. Hypertrophy of the Anal Papillae. - - In devoting some space to the anal papillae, the author has done so with the view of bringing before the profes- sion a condition which is practically never recognized by the general practitioner; and usually overlooked by the general surgeon, who includes rectal surgery as an inci- dent in his practice. It is one of the many minor condi- tions which originate in the anal canal which, while never causing such serious symptoms as to endanger health or 212 HYPERTROPHIED ANAL PAPILLAE. life, or to cause such great suffering as to incapacitate the patient from his daily occupation; nevertheless, is of no small interest to the medical practitioner because of the amount of discomfort it causes. This may only amount to an uneasiness, hut the hyper- trophied anal papilla is often responsible for symptoms ridiculously out of proportion to the size and severity of the lesion. Many irregular practitioners who hold themselves out as "rectal specialists," have made great capital out of the anal papillae and have attributed to them the causa- tion of nearly every disease in the calendar. As a result, many of the profession have gone to the other extreme, and have completely ignored the existence of what has been proved to be definite diseased conditions of definite anatomical entities. When a patient complaining of indefinite rectal or anal symptoms consults his physician, too often he is dis- missed with some proprietary ointment, without any ef- fort being made to locate the cause of the trouble. The special study of the Rectum, with its allied organs, the Anus and the Sigmoid, has brought to view many inter- esting conditions which have been overlooked in the past ; and it is with the view of clearing up some of the obscure and indefinable symptoms which originate in the region of the anus, that the author is devoting this space to Hypertrophy of the Anal Papillae. It is in the anal canal, where most of the pathological conditions which cause pain and suffering, and reflexes without number originate. Nature has been unusually lavish in her sensory nerve supply to these organs, and lesions in this region produce referred disturbances in HYPERTEOPHIED ANAL PAPILLAE. 213 many other and remote organs. When one considers that the anal canal measures from two-thirds to an inch and a quarter in length and its circumference about one and one-quarter inches in the contracted condition; one can readily see that it is not a large area to examine and study, and diseased conditions in this region should not be difficult to discover, diagnose, and remedy. Fig. 93. Sectional View of the Anal Canal Showing Hypertrophied Anal Papil- lae and Crypts of Morgagni. C Opening of Crypt of Morgagni. P. Hypertrophied papillae. N. Normal papilla. 214 EXAMINATION AND DIAGNOSIS. The anus is peculiarly susceptible to injury and disease. First, because its lining membrane being neither skin with its tough resisting power nor mucous membrane with its generous vascular supply, but a sort of transi- tional tissue, neither one nor the other; is easily injured. Secondly, any lesion occurring in this region has a small chance of recovery, because of its meagre blood } supply, its constantly changing position, and because of trauma and infection by the contents of the bowel which are constantly passing over it. In order to understand more intelligently the condition under discussion it might be well to say a few words about the normal anatomy of the anal papillae (Fig. 92), These papillae occur as an irregular line of small saw- tooth like projections encircling the point of the juncture of the anus with the rectum, sometimes called the linea dentata. These papillae, varying in number from five to a dozen, are usually situated at the edges of the semi-lunar anal valves or crypts of Morgagni. Andrews considers these papillae the normal tactile organs of the rectum and endowed with a special rectal sense. They have an abund- ant nerve supply, which accounts for the many reflex dis- turbances which originate when they are diseased. Examination and Diagnosis. In making a digital ex- amination, unless one is rather expert, these papillae are not always evident to the touch, but are apt to be over- looked unless an ocular inspection is made. When dis- eased, these papillae may vary in size from a quarter of an inch in length, by the same breadth at the base, to an inch and a quarter or an inch and a half in the longest diameter. (Fig. 93). They are composed largely of an over-growth of normal tissue. Often by everting the DIAGNOSIS. 215 anus, the tips, and often all of the hypertrophied papillae themselves can be brought into view (Fig. 94). They are of a pinkish color, slightly paler than the normal mucous membrane of the rectum. Fig. 94. Hypertrophied Anal Papillae. Drawn from a photograph of one of the author's cases. This well shows the appearance of the anal papillae when the anal margin is put upon the stretch by strong traction. A distinguishing point between hypertrophied papillae and polypi in the fact that the hypertrophied papilla is always wider at its base than the apex, while the polypus is always larger than the pedicle by which it is attached. The polypus is usually rounded or oval in shape, while the papillae is more or less triangular, or ribbon shaped. Enlarged papillae have been incorrectly designated as 216 DIAGNOSIS. connective tissue piles. They never show the character- istic varicose appearance of the internal hemorrhoid and are attached at the ano-rectal line. Fig. 95. Proctoscopic View of an Exaggerated Case of Hypertrophied Anal Papillae. Containing some erectile tissue, on examination through the anoscope, they will often be seen to stand out at right angles from the mucous membrane; giving the anal canal at this point somewhat of a fringed ap- pearance. (Fig. 95). Many a surgeon, when he can dis- cover no pathological lesion but finds a tight sphincter, overlooks what he may call "little tags of the mucous membrane. ' ' These are very frequently the cause of the tight sphincter; for let it be said here that no sphincter is abnormally tight, unless there is some pathological SYMPTOMS. 217 lesion causing it; and a simple divulsion of the sphincter will not relieve the symptoms, as many a surgeon and patient have found to their chargin and disappointment. Symptoms. These papillae being situated on the edge of the Morgagnian crypts, are pushed and dragged downward during the passage of feces, which are more firm and harsh than normal. At each bowel movement there is a farther pull and drag on the papilla, which is gradually .stretched and hypertrophied. After it has become sufficiently hypertrophied it will not retract at once after a movement, but will remain in the grasp of the internal sphincter, causing it (the sphincter) to con- tract. This contraction gradually becomes more tonic, and eventually we have what has been called the "tight contracted sphincter." This gives rise to one of the most characteristic symptoms of hypertrophied papil- lae, or that of an unsatisfied feeling after stool ; a feeling as if some particle of fecal matter were still in the grasp of the sphincter and could not be expelled. Also a feel- ing of irritation and uneasiness, short of itching. As one patient described it to me, "It felt like the bite of some small animal," and he was sure that he had a tape worm, because he ' ' could feel it nibbling at the anus. ' ' Another stated that it felt like a burr, held in the grasp of the sphincter. This feeling can be immediately relieved by the insertion of the lubricated finger and pushing up and replacing the enlarged papillae which will be found in the grasp of the internal sphincter. If they are left to them- selves, it will often take from fifteen minutes to an hour and a half or two hours for them to gradually retract; when symptoms will entirely disappear. They cause spasm of the sphincter, and the constantly repeated 218 CRYPTITIS. spasm brings on a hypertrophy of the circular muscular fibres, forming the sphincter muscles, and the hypertro- phied sphincter is the so-called 'tight sphincter." Another symptom which the hypertrophied papillae cause is so-called neuralgia of the rectum, being trans- ferred and transmitted pains from pressure on the nerve endings of the papillae. One of the most common symp- toms, however, for which hypertrophied papillae is re- sponsible, is pruritus ani. I do not wish to be misunder- stood as saying that hypertrophied papillae are the only cause of pruritus ani, because the causes are legion; but it is a common and probably the most frequently overlooked cause. Cryptitis. It will be remembered that each papilla is found at the edge of the semilunar valve, which semilunar valve is the outer boundary of one of the crypts of Morga- gni, also known as rectal pockets or mucous crypts. These crypts, whose function is not thoroughly understood as yet, become clogged with fecal matter, which on account of the shape of the crypt or sac is not readily extruded. The enlarged anal papilla overlying the crypt assists in preventing its escape. The decomposition of this fecal matter or retained secretion and the consequent irrita- tion of the crypt, sets up an inflammation or cryptitis. which may go on, and does frequently, to pus formation. The accumulated discharge originating here overflows from the crypt, and as it runs down the mucous mem- brane of the anus, sets up an irritation, which is made manifest by itching or pruritus, and the moisture com- plained of by many patients suffering from pruritus will be found to originate from this cause. SYMPTOMS. 219 The feeling of uneasiness following stool, which some patients complain of, is unlike that produced by any other condition. It has been described to me by one pa- tient, as a feeling as if he had thorns or pine needles in the anus a sort of prickling sensation not painful but very uncomfortable ; and he would find himself constant- ly shifting from side to side as he sat in a chair. Occa- sionally the shifting would relieve him, when assisted by some pressure on the anus, thus releasing the papillae from the grasp of the sphincter. It is not only the extremely long papilla that we must look for to cause these symptoms; as those which are only half an inch in length, the tips of which are just engaged in the sphincter, are sufficiently long to cause symptoms. Another condition which has been found to follow the hypertrophy of an anal papilla is fissure-in-ano. This is caused, as has been demonstrated by "VVallis, of St. Mark's Hospital, London, by sufficient pressure during stool to tear the papilla downward from the edges of the crypt, and succeeding stools continuing the tearing process, the edge of the crypt is brought down to the outside of the anus; leaving in its wake a raw, ulcerated furrow (see Fig. 61), which is split open further by each stool, and gives rise to the many severe and intolerable symptoms attending upon fissure in ano. Treatment. The treatment of this condition is ex- tremely simple and consists in the removal of the papil- lae when they are enlarged, and the opening and cauteri- zation of the crypts when inflamed or infected. Both conditions are present together so often that their treat- ment will be considered together as well. The removal 15 220 TREATMENT. of papillae is accomplished in the following manner : The anoscope, or fenestrated speculum, is inserted, with the opening directed towards the lowest papilla to be re- moved. The papilla is injected at its base with the one- tenth of one per cent solution of eucain, or half of one per cent of chloretone, and distended to whiteness. The papilla is then removed as close to its base as possible by means of the snare, excision, or crushing. It is never necessary to anesthetize the sphincter; and oftentimes the anoscope or speculum is not required. By eversion of the anus (Fig. 94), the papilla may be brought into view and anesthetized and removed while thus exposed. No dressing is required; the hemorrhage, which is slight, soon ceases, and no after-care is necessary, other than that employed following the operation for simple fissure. When one of the Morgagnian crypts is inflamed, the area surrounding the crypt, including the papilla, should be injected and distended with the one-tenth of one per cent solution of eucain and a V-shaped incision made from above ; the base being at the extremities of the crypt and the apex one-half inch below its centre. This incision should be deep enough to well open the crypt. The flap, which includes the papilla, is removed, and its base cau- terized with chromic acid, which has been previously fused on the end of a probe. A suppository containing two grains each of chloretone, thymol iodide and powdered opium is then inserted. Where more than one crypt is involved, the same technique is employed for all ; the low- ermost crypt being operated first, and the others injected in turn just before operating. The after care is the same as has been described for hypertrophied papillae. CHAPTER XII. PROCTITIS AND SIGMOIDITIS. This consists of a catarrhal inflammation, either acute or chronic affecting the mucous membrane lining the rec- tum, sigmoid flexure or entire colon. There are many varieties of inflammation affecting the rectum and sig- moid due to the invasion by the micro-organism of gonor- rhoea, syphilis, diphtheria, erysipelas and dysentery. With the exception of the last named variety, the inflam- mation caused by the micro-organisms of dysentery; the other varieties accompany or are caused by diseases af- fecting other organs and occur as a complication, and will not be described in this chapter. Amoebic dysentery will be discussed fully in a separate chapter. The author therefore will limit himself to discussion of simple catar- rhal proctitis and sigmoiditis, acute and chronic. Acute Proctitis and Sigmoiditis. Etiology. This disease occurs at all ages, children being affected as frequently as adults. Among the pre- disposing and causative factors are sudden changes in climate, weather, or mode of living ; the ingestion of high- ly seasoned foods, condiments, and excesses in the use of alcohol or tobacco. Constipation is occasionally a causa- tive factor, but the presence in the rectum of intestinal parasites, impacted feces or foreign bodies as well as 221 222 ACUTE PROCTITIS ETIOLOGY AND SYMPTOMS. infection of the rectum, from unclean enema tips or ex- amining instruments are more often responsible for its onset. Patients suffering from rheumatism and gout or those who are peculiarly susceptible to sudden chilling of the skin surface are particularly liable to attacks of acute catarrhal proctitis. Acute indigestion, with its at- tendant fermentation of food products in the intestinal tract and ptomaine poisoning are very prolific sources and inflammation by extension from any acute pelvic dis- order is not uncommon. The use of drastic cathartics is also an etiologic factor of no small importance, and the ingestion of many food articles which in some individ- uals, cause urticaria of the skin surfaces, will often be responsible for an attack of acute catarrhal proctitis. Symptoms. Its onset is attended oftentimes by a chill, slight rise of temperature and a sense of uneasiness in the rectum and lower abdomen; oftentimes accom- panied by backache, particularly over the sacral region, and occasionally shooting pains down the limbs. This is followed in a few hours by a sense of fullness and heat in the rectum, with a constantly increasing desire for stool. Disturbances of the bladder are noted ; particular- ly a desire to urinate frequently and a burning sensation when doing so. The patient is most comfortable lying on his side. The movements become soft and frequent evacuations occur. At first the movements are those of ordinary diarrhoea; after the first day or so, the move- ments consist more largely of feces mixed with mucous and sometimes tinged with blood. If the disease prog- resses and ulceration occurs, the movements contain blood and pus, and a muco-purulent discharge will be noted at the anal orifice between movements as well. In children, ACUTE PROCTITIS DIAGNOSIS AND TREATMENT. 223 this condition frequently brings about prolapse of the rectum, and occasionally also in adults. Diagnosis. With the history of an onset such as has been given above, examination of the rectal cavity is indicated. With the patient in the knee shoulder posi- tion the proctoscope should be inserted and the rectum inflated. If the insertion of the proctoscope is accompa- nied by considerable pain, as it will be in many cases suffering from proctitis, the sphincters should be first anesthetized according to the technique outlined in Chap- ter XV. The appearance of the mucous membrane of rectum is somewhat characteristic. Upon ocular examin- ation, the rectal mucous membrane is bright red in color, its appearance being not unlike the appearance of the in- flamed conjunctiva, the difference being that the rectal mucous membrane will be more of a brick red, and the mucous membrane appears somewhat velvety and oede- matous. An increased quantity of stringy, yellowish colored mucous will be noted. The blood vessels of the rectal wall, and particularly on the valves of Houston, will be found deeply injected and clearly outlined, stand- ing out distinctly from the red mucous membrane. Treatment. The treatment of acute catarrhal proc- titis is dietary, systemic and local. In those cases de- pending for their origin upon the presence in the rectum or sigmoid of impacted feces or foreign bodies, their re- moval is first indicated. Where the proctitis is caused by ptomaine poisoning from decomposition of food ma- terial in the intestinal tract, prompt and free catharsis is the first essential. Patients suffering from systemic or constitutional diseases in whom the proctitis is merely a complication, should of course receive general medical 224 ACUTE PKOCTITIS LOCAL TREATMENT. treatment for the underlying constitutional or systemic trouble. Where irritating or improper food material is the caus- ative factor, or the indulgence in alcoholic stimulants or tobacco to excess is responsible, their interdiction and withdrawal is obvious. In the local treatment of acute catarrhal proctitis, co- pious irrigations of the rectum sigmoid and colon with normal saline solution, at a temperature of 110 to 115 F., given twice or three times during the twenty-four hours, has in many cases been sufficient. In irrigating the colon, the position in which the best results are achieved are either the knee- shoulder, left lateral or Sim's, or the lithotomy. Where either of the latter positions are employed, the hip should be elevated considerably higher than the head. The irrigator, or fountain syringe, to be placed from one and a half to two feet above the level of the anus, and the flow checked by pressure on the tubing, when there is a desire on the part of the patient to expel the fluid before a suffi- cient quantity has been administered. This uncomfort- able feeling is due to the over-distension of the bowel at certain points when the inflow is interrupted either by the normal sacculations or spasmodic contraction of the circular muscular fibres. This sensation will soon pass away, however, if the inflow is checked for a moment so as to allow the solution already in the bowel to flow higher up. Changing the position of the patient from one side to the other and massaging the abdomen gently will great- ly assist in the distribution of the irrigating fluid. By this method, the majority of patients will be able to re- ACUTE PBOCTITIS LOCAL TREATMENT. 225 tain a sufficiently large amount of the irrigating fluid to thoroughly flush the entire colon. Fig. 96. Spraying the Rectum With the Patient in the Knee- Shoulder Position. On account of the ballooning out of the rectal cavity by air inflation in the knee-shoulder position, this position is ideal for the application of sprays to the rectal surfaces. In those cases where the mucous discharge from the rectum or sigmoid is profuse, the use of nitrate of silver solution in strengths ranging from one to five per cent, by means of the rectal spray, has been found very effica- cious. The author uses a metal spray tube attached to the hand atomizer or used with the compressed air tank, which is nine inches in length. Its distal extremity is closed, but from its circumference, about one-sixteenth of an inch from the end, the solution issued in all direc- tions from four small apertures, so that the solution is not thrown any higher into the bowel than one wishes, 226 ACUTE PKOCTITIS TREATMENT. but bathes all surfaces alike (see Fig. 97). The rectum and sigmoid is best sprayed with the patient in the knee- shoulder position (Fig. 96). In some cases, where the mu- cous flow appears to come from higher up in the bowel, irrigations of the colon with various astringent solutions, are indicated. Two to five per cent solutions of alum answer very nicely, and the aqueous fluid extract of Kra- meria from five per cent to twenty per cent as advocated by Tuttle, has proved of value in the author's hands. Fig. 97. Author's Rectal Spray Tube. The tip being closed and the solution issuing from its circumference only, it is impossible to throw irritating solutions like nitrate of silver higher into the bowel than one wishes. While many authors advocate the confining of the pa- tient to bed during the treatment for acute catarrhal proctitis, the author has found no difficulty in securing results by allowing the patient to be up and around for a greater portion of the day. He believes that better drain- age of the intestinal tract is secured at all times by the upright position. In some cases where results are not obtained by spraying with aqueous solutions, and where ACUTE PROCTITIS TREATMENT. 227 there is a tendency for the bowel walls to ulcerate the insufflation of various powders will be found of great value iodosyl, compound stearate of zinc with balsam peru or boric acid, thymol iodide, have all been found very satisfactory in these cases. Fig. 98. DeVilbiss Spray Tube. Provided with an adjustable tip so that the spray may be thrown in any direction. Ulcerating spots should be touched up with pure ich- thyol or solutions of 5 per cent or 10 per cent of nitrate of silver. The author is not in sympathy with the use of solutions of the stronger chemical antiseptics such as the bichloride of mercury or carbolic acid, even when used in very weak solutions; he believes that more harm is ac- complished by the action of the irritating chemical solu- tions on the weak and debilitated lining mucous mem- brane, than whatever little good they accomplish by their action as antiseptics. In irrigating or flushing the colon, the recurrent flow soft rubber colon tube devised by J. L. Jelks, of Mem- 228 ACUTE PROCTITIS TREATMENT. phis, Tenn., will be found a very useful piece of appara- tus. For the technique of its use the reader is referred to the following chapter on dysentery. During the treatment of a case of proctitis or sigmoiditis, the patient should be kept on a light and unirritating diet in which the vegetable elements are largely eliminated. The thin cereal gruels prepared from oatmeal, rice and barley, egg albumen, the various flavored gelatines and liquid peptone solutions will be found best for use in these cases. Milk is contra- indicated on account of its tendency to constipate, and the fact that it forms hard curds which only further irri- tate the already sensitive bowel. Internal medication is not of much avail; the use of ichthyol in 2 to 5 gr. doses given in double capsules four times daily, the author believes has given some good re- sults. He has found the employment of white refined petroleum oil or liquid albolene to be of particular value in proctitis. It seems to have a specially soothing effect on the inflamed and irritated mucous membrane of the bowel and while it does not produce or stimulate peristal- sis, it causes easy and free evacuation by its mechanical softening and lubricating effect. Being a mineral oil of no food value and having no medicinal effect, it is not acted upon by the digestive secretions, and passes through the intestinal canal unchanged. The patient should be instructed to drink six to eight glasses of water daily; if there i.s any doubt as to the purity of the water, it should be boiled and then kept in bottles on ice. In order to remove the flat taste of boiled water, the author would suggest that before use it be poured into an open vessel or pitcher and stirred up with a revolving egg beater. This aereates the water so that CHRONIC PROCTITIS AND SIGMOIDITIS. 229 it again tastes fresh and clean, and effectually removes the unpalatable taste which is one of the drawbacks to the use of water sterilized by boiling. The use of flax- seed tea is often of assistance in these cases. If properly prepared is of distinct value. A good way to prepare flax-seed tea is as follows : Take four or five tablespoons- ful of whole flax seed and place in a shallow pan. Pour over this a quart of boiling water, place the pan over the flame and allow to boil for five minutes, then strain through muslin and allow it to cool. It is best kept on ice until ready to use. If it is desired to sweeten or flavor the flax-seed tea, lemon juice, oil of peppermint or winter- green and sugar may be added in quantities to taste while the tea is still hot. A teacupful should be taken as hot as can be comfortably borne every night at bed time. This will act, often, as a mild cathartic and seems to have some soothing influence on the mucous membrane of the bowel. Chronic Proctitis and Sigmoiditis. This disease is usually of two varieties, hypertrophic and atrophic. The atrophic variety is the most common variety of chronic proctitis or sigmoiditis met with. The hypertrophic variety may follow an attack of acute proc- titis or sigmoiditis but is often produced by other dis- eased conditions outside of the bowel. Pressure from ab- dominal tumors, movable kidneys, uterine displacements, extension from pelvic cellulitis and adhesions following inflammatory conditions of the pelvis may all set up at- tacks of hypertrophic proctitis and sigmoiditis. Appen- dicitis has also been mentioned as an etiological cause. The atrophic variety may often be brought about by a long period of chronic constipation; the abuse or ex- 230 CHRONIC HYPERTEOPHIC PROCTITIS SYMPTOMS. cessive use of cathartics extending over a long period of time ; excesses in both eating and drinking, particularly in people of sedentary habits. Other causes of a more local nature are repeated attacks of fecal impaction ; the enema habit, foreign bodies in the rectum and unnatural practices. Chronic Hypertrophic Proctitis. This variety is dis- tinguished from the atrophic variety by the fact that the mucous membrane and submucosa are always thick- ened, and the glands as well as the inter-glandular con- nective tissue hypertrophied and increased. The anal papillae are usually very much enlarged in this condi- tion. On proctoscopic examination, the appearance of the mucous membrane is somewhat characteristic. Tut- tle well describes it as follows: "Through the procto- scope it appears oedematous, paler than usual and cov- ered with a thin coat of whitish secretion. The swollen membrane bulges out into the fenestra of the conical speculum, or falls down and completely covers the end of the proctoscope. When the muco-pus is wiped off, the membrane presents through the magnifying glass a cauliflower-like appearance, whitish and granular. It does not bleed easily, and the end of a fine probe being- pressed down upon its surface, the tissues will meet to- gether above it. By scraping with a rectal scoop one may obtain a certain amount of muco-purulent fluid, con- sisting of pus cells, leucocytes and various bacteria, to- gether with small masses of fecal matter and undigested particles of food." Symptoms. The disease may be of insidious onset, or it may be the continuation of an attack of acute catar- rhal proctitis. The patient is usually in a run-down CHRONIC HYPERTROPHIC PROCTITIS DIAGNOSIS. 231 condition, and presents the usual symptoms of such a state, such as impaired appetite, foul breath, indigestion, gaseous eructations, diarrhoea, occasionally alternating with constipation, a frequent desire to move the bowels without much result and an unsatisfied feeling as if something more were to pass away after a stool. Where the bowels are loose, the stools are inclined to be of a pea soup consistency, consisting quite largely of muco-pu- rulent material, or there may be small hardened boluses or scybala covered with sticky mucus, or muco-pus. On account of the hypertrophied condition of the mucous membrane, prolapsus is met with in some cases, and pruritus ani is a frequent symptom. The secretion keeps the region of the sphincter constantly moist and is oc- casionally so profuse and constant that the patient has to wear an absorbent dressing to prevent it from soiling the clothes. On account of the constant moisture of the part, condylomata are occasionally found, particularly at the posterior aspect of the anus and anal canal. Diagnosis. The diagnosis is made upon proctoscopic and sigmoidoscopic examination. The characteristic hypertrophied appearance of the mucous membrane, with the presence of muco-purulent discharge, with or with- out ulceration of the mucous membrane, accompanied by a history of symptoms such as have been given above, should make the diagnosis not difficult. The condition is, fortunately, not very common. Treatment. If upon examination of the patient such extra-rectal causes as appendicitis, floating kidney or abdominal or pelvic growths impinging upon the bowel are discovered, the indicated surgical measures for their relief should be carried out. The patient's dietary 232 CHRONIC HYPERTHROPHIC PROCTITIS TREATMENT. should be corrected and all condiments, alcoholic stimu- lants, pastries, salads, sweets, fresh fruits and freshly baked foods prohibited. In order to give as little work to the intestines as pos- sible, the patient should be put on a diet which is largely assimilable, such as: eggs, the various gelatins, lean meat, poultry, fresh water fish and small quantities of green vegetables such as spinach, beet tops, lettuce, en- dive and kale. The patient should be encouraged to drink large quantities of cold water and should try to have a bowel movement at regular hours. Liquid albolene in doses varying from one to four drachms three or four times a day should be administered on account of its soothing influence upon the mucous membrane of the intestinal tract, and because by its admixture with the f eces, it prevents the formation of hard, irritating masses. Where symptoms of intestinal indigestion are present the author has found pancreatin in ten-grain doses, tak- en with or directly following the meal, of considerable value. Ichthyol in double capsules, in doses of from two to five grains four times daily seems to be of some serv- ice. The bowels should be flushed morning and night with some astringent solution such as is used for the treatment of acute catarrhal proctitis. Tuttle recom- mends very highly the use of one to three quarts of a two to ten per cent solution of the aqueous fluid extract of krameria. This is best given with the patient in the knee- shoulder position and through a Jelks' recurrent flow colon tube. The preparation of the aqueous fluid ex- tract of krameria as described by Tuttle is as follows: ''Macerate one pound of bark of krameria in a long percolating tube for twenty-four hours. After this a CHRONIC HYPERTHROPHIC PROCTITIS TREATMENT. 233 mixture of 20 per cent glycerin and 80 per cent water is allowed to percolate through it. The percolate should be constantly stirred and refiltered through the bark the second time. The filtrate is then evaporated down to one pound, thus obtaining an aqueous fluid extract con- Fig. 99. Ulcer of the Rectum. This case well illustrates the importance in proctoscopy of examining the cavity behind each rectal valve. In this patient the ulceration was situated on the right lateral wall of the rectum, and had not the first rectal valve been pushed aside by the proctoscope its presence might have escaped unnoticed. 234 CHRONIC ATROPHIC PROCTITIS AND SIGMOIDITIS. taining grain for grain all the therapeutic properties of the bark. The preparation should be kept in a dark place and not exposed to the air." If, on proctoscopic or sigmoidoscopic examination lo- calized ulcerated areas (Fig. 99) are discovered, they should be sprayed with a 1 to 3 per cent solution of nitrate of silver or 5 per cent solution of ichthyol. They may be stimulated by the application of nitrate of silver 5 to 10 per cent applied with a long handled applicator or pure ichthyol or balsam peru. The general condition of the patient must be improved by ordinary tonic measures and the encouragement of moderate exercise in the open air and sunshine. Chronic Atrophic Proctitis and Sigmoiditis. This variety is more common than the hypertrophic, and consists of a general atrophy of both the glands and intra-glandular structures of the rectum and sigmoid. It differs from the hypertrophic variety in that it does not frequently extend higher than the sigmoid flexure and there is a thinning or destruction of the mucous membrane lining of the bowel. The pathology of the condition is well described by Tuttle as follows: ''One observes upon examining the mucous membrane in these cases an irregular, bosselated or granular ap- pearance. The surface is dry, rough, inelastic and with- out any salient vegetations. Attached to the surface here and there are small masses of dry fecal material, and occasionally little islands of necrotic epithelium or pseu- do-membrane. ' ' Microscopic examination shows the epithelium absent in many places, but always present in the deeper por- CHRONIC ATBOPHIC PROCTITIS SYMPTOMS. 235 tions of the crypts of Lieberkiihn. These follicles are generally atrophied, the intratubular tissue decreased, and their goblet cells are few in number. The cylindrical epithelium is said to assume the stratified pavement type in this disease. This change does not extend more than 1 or 2 centimetres above the ano-rectal line; it is con- fined to the superficial structure of the membrane, and does not involve the tubules. "The connective tissue of the submucous coat is dense and slightly thickened; it does not contain embryonic tissue and elastic fibres, as in the hypertrophic form. The solitary follicles are often enlarged and distended. At points there are distinct granulations, and ulcerations, accompanied with hyperemia and multiplication of the blood vessels, but there is no alteration in the blood ves- sel walls." Symptoms. As has been stated, this condition super- venes frequently on an old long standing case of con- stipation. The stools are small, hard and dry, and their passage is painful; they are often streaked with blood, pus and mucous. The patient suffers from tenesmus, referred pain in the sacral region and down the legs. The rectum feels hot and feels after stool, as if it were not emptied. This feeling is not like the sense of full- ness which is more characteristic of the hypertrophic variety; but more a sense of uneasiness which focuses the patient's attention upon the rectum, which makes him feel that the emptying of the rectum will bring him relief. Pruritus ani is a frequent symptom as well as spasm of the sphincters. On account of the contracted condition of the anal canal, the passages are frequently followed by the production of small fissures or cracks 16 236 CHEONIC ATROPHIC PEOCTITIS TREATMENT. in the mucous membrane. Their presence adds a sting- ing or burning sensation to the other symptoms of the disease. These fissures are very superficial and are not to be confounded in any sense with the true or typi- cal fissure in ano. They consist merely of linear abras- ions in the lining membrane of the anal canal, and lack any tendency to chronicity which is characteristic of a true fissure. Hemorrhoids are said to be found fre- quently accompanying this condition. With the patient in the knee- shoulder position, procto- scopic examination shows the mucous membrane to be reddened but not markedly as in the acute variety; dry, and covered here and there with small flecks of dry fecal matter. The insertion of the proctoscope is usually ac- companied by some hemorrhage due to the passage of the instrument. On examination of the rectal walls num- erous pin point ulcerations are met with. The mucous secretion which is very slight in this condition, clings to the bowel wall, and is characterized by thickness and tenacity. In this condition the mucous membrane does not fall together before the proctoscope and the rec- tum gives the appearance of being a stiff tube, while the rectal valves stand out very markedly. Ulcers other than the pin point variety are not uncommon, and tend to become chronic and to gradually encircle the bowel, producing a strictured condition. Treatment. In this condition the presence or ab- sence of syphilis should be ascertained. Where either from the ignorance of the patient of his true condition or from his reticence about the matter one cannot obtain a definite history, the Wasserman test, or serum diag- nosis should be resorted to. If positive, the ordinary CHRONIC ATROPHIC PROCTITIS TREATMENT. 237 measures for the treatment of syphilis in the third stage should be employed. The diet is exactly the same as that outlined for hypertrophic proctitis, with the ex- ception that the patient may have fatty food, bread (not freshly baked), toast, rice, sago and custards. Where intestinal indigestion is present pancreatin should be ad- ministered and liquid albolene given as outlined in the treatment of the hypertrophic variety. As this condi- tion is usually confined to the rectum and lower sigmoid, the high irrigations will not be necessary, but the solu- tions mentioned are equally applicable for the flushing of the sigmoid and rectum in this variety. After irrigat- ing the rectum, the patient should be put in the knee- shoulder position and under the guidance of the eye, ul- cerated patches on the mucous membrane should be touched up through the proctoscope with 2 to 5 per cent solution of nitrate of silver, iodine or pure icthyol. Icthy- ol in 5 per cent aqueous solution is very valuable as a spray in this condition, as is the fluid extract of kram- eria in strength ranging from 20 to 30 per cent. The treatment of the accompanying conditions such as fis- sures, hemorrhoids and pruritus should be carried out as outlined under the respective chapters. What has been said before regarding exercise and fresh air is equally applicable in this condition. CHAPTER XIII. DYSENTERY. By JOHN L. JELKS, M. D., Memphis, Term. Synonyms. Colitis, Ruhr or Dysenteric (German), Difficultas Intestinorum (Latin), Au? evrcpov (Greek). Definition. An acute or chronic inflammatory dis- ease, usually affecting the large intestine, beginning in the rectum but sometimes extending into the small bowel. In the acute form it is characterized by pain, tenesmus, and frequent passages of bloody mucus. In the chronic form the patient suffers recurring attacks of diarrhoea alternating with constipation. Historical. Dysentery was one of the best known diseases of antiquity. Even before the time of Hippo- crates, reference to it was made; the earliest being that found in the papyros of Ebers'. Hippocrates, in the year 460 B. C., was the first writer to give a fairly accurate description of its symptomatology, pathology, and se- quellae. Other well known writers were Celsus, the medical Cicero of his day (45 A. D.), Aretaeus, Galen, and Alex- ander of Tralles. Then for more than a century little further knowledge was imparted until the time of Antonio Benivieni (1506), and Thomas (1833), who refuted many of the erroneous ideas of his predecessors. Woodward 238 DYSENTERY GENERAL ETIOLOGY. 239 (1879) gave a most excellent history of this disease (Med- ical and Surgical History of the War of the Rebellion, Vol. 2). Kartulis, in Egypt (1885), Flexner (1890), Coun- cilman and Lefleur (1892), Shiga of Japan (1897), Strong and Musgrave, and Harris, of Atlanta, of the present era, have contributed perhaps the most valued writings. Osier, Tuttle, and Surgeon General Sternberg of the United States Army are also among those who have fur- nished valuable data in our own country. The writer of this chapter has also made close study of this disease in the Southern States. Geographical Distribution. Dysentery does not re- spect any country, climate or race. Ayers very truthfully states, that, where man is found, there some of its forms appear. A. Hirsch says it had a wide distribution over the inhabited earth at all historic times. It is without doubt one of the four great epidemic diseases of the world. In the tropics its ravages have been most deadly, destroying more lives than cholera, and to the armies it has been more destructive than powder and shot (Osier). Dysentery is a destructive giant compared to which strong drink is a mere phantom (McGregor). The worst outbreaks occur as endemics in the tropics and decrease as we leave this latitude, while in the higher latitudes it seldom appears in this type, though now and then in greater or less epidemics. A very striking fact relative to this affection is that it involves the cold zones. Epi- demics have been reported in Alaska, Sweden, Russia, Greenland, and Iceland, also others of the colder coun- tries. General Etiology. Season. Among the predispos- ing causes season is the most important. More cases of 240 DYSENTERY ETIOLOGY. dysentery are found during the summer and autumn months. This is due to several reasons. Sudden changes in temperature, especially sudden rises, have a most marked effect. It is most prevalent in the warm cli- mates, and, as stated above, it is most deadly in the tropics. Therefore, climate should be mentioned as one of the causative factors. Race. Race itself does not seem to affect this disease. Strange, though it may seem, the negro race in the South has not seemed to suffer much, with reference to this disease; notwithstanding the baneful consequences of poor hygienic conditions as overcrowding, improper food, poor ventilation, filth, thin clothing, and especially syphilis a disease almost universal among this race, either inherited or acquired. These, however, must all be included under predisposing causes. Sex. Under etiology, we should also mention sex. Within our experience, which is not at variance with that of other writers, dysentery is much more common among males. Poor Hygiene. In the slums of our cities, where filth abounds and where proper sewerage is lacking, we find more cases of dysentery than in the sections where the hygienic conditions are better. Many cases are found in institutions such as insane asylums, barracks, jails and army camps. Wherever there is over-crowding, there is very apt to be found a large percentage of dysenteric cases. During the Civil War, Woodward reported 259,071 cases of acute dysentery, and 28,451 of the chronic form, in the Federal service alone. Topography and Conditions of Soil. Investigators have tried to associate dysentery with certain topographi- DYSENTERY ETIOLOGY. 241 cal conditions, or with conditions in the soil, but have been unable to do so. Epidemics have proven more fatal in the country than in the city. Soil that is badly contaminated with dysenteric ex- creta is a great source of infection. Czernicki tells about dysentery breaking out in two French squadrons in 1875 that were on the same ground occupied a short time pre- viously by a cavalry regiment which had been affected with the same disease. The writer has often found nests of dysenteric cases in the low flat mill districts of the city, and in marshy low- land sections of the country. No doubt, owing to the char- acter of the soil in these localities, seepage contamina- tion of drinking water sources sometimes occurs. Houses built upon a low damp soil are unsanitary, and, when the surrounding soil always remains saturated with moisture, there exists a favorable condition for the development of dysentery. The peculiar emanations from soil of this kind have always been considered very harmful. It is thought that they have a depressing influence upon the inhabitants, and thus make easier the inroads of dis- eases. In one ill-drained low district of Memphis, the writer treated six cases of amebic dysentery within a radius of two blocks, and a seventh case was seen that had been infected in the same territory five years before. It is also an interesting fact to note here that two families, in which were four of the patients, purchased vegetables from the same Italian huckster. There is yet another reason why we find more cases in the marshy low-land districts. Here we find the greatest 242 DYSENTERY ETIOLOGY. growth of vegetation, which, when conditions are favor- able, furnish a most suitable nidus for the propagation and development of amsbae, bacteria, and other micro- organisms. Foods. Certain articles of food are unquestionably predisposing causes in dysentery. This fact is not due so much to an idiocyncrasy to any particular foods, but mainly to the micro-organisms which they contain, and to the putrefactive changes which occur within the intes- tinal tract. All grounding vegetables and fruits, especi- ally those shipped from the tropics, are possible sources of infection. Undoubtedly infections with the amebae have been traceable to eating such vegetables as lettuce, strawber- ries, cress and potatoes. Eating food in excess, and the resulting attacks of indigestion often pave the way for dysentery. Drinking Water. The writer has given much thought to water supply as a medium through which dysenteric infections are conveyed. This is undoubtedly the most common source. We have been impressed by the fact that many cases are found among sportsmen, also tim- bermen who spend much of their time in the woods, and who drink, when necessity requires, from surface pools, springs and slashes. The writer has treated a case of amebic dysentery from a country district with which he is quite familiar, and has knowledge of the fact that the disease was con- tracted in the same infected neighborhood in which twenty years previous another case had lived, which proved fatal. The fact has been elicited that many of the writer's cases had neighbors suffering in like manner, DYSENTERY CLASSIFICATION. 243 and who were procuring their drinking water from the same source. There are certain rivers in China whose waters are known to cause dvsenterv. > * In 1863, the number of cases among the workmen con- structing the Suez Canal was decreased when the better water of the Nile was used. The writer has treated one case of amebic dysentery in the person of a physician, who thinks undoubtedly that the infection was obtained from drinking Mississippi River water while on board a river steamer. Thevenol says, "Nothing is so prone to lead to disorganization of the large intestine as infected water." Impure water itself does not produce dysentery, but only when it contains the special micro-organisms. Classification. Acute Catarrhal Dysentery or Spor- adic Bacillary Dysentery: This form is the least severe and most common form that is encountered. It occurs both sporadically and endemically. This type is characterized by the frequent passage of great quantities of mucus. Special Etiology. Children principally are infected with this form, but we often see it in adults, most often complicating other diseases. It is the kind of dysentery that accompanies all of the exanthemata. We see it in fact, complicating almost all the acute infectious diseases. Still another important cause is the ingestion of certain kinds of foods, or other irritating substances. The ordi- nary attacks of entero-colitis in babies during the summer months come in this classification. Most of these attacks are due to milk poisoning. 244 ACUTE CATARRHAL DYSENTERY. Pathology. Macroscopically a superficial, acute in- flammation involving the large intestine, but sometimes extending into the small bowel, is seen. The tendency of such cases is to recover without necrosis. Sometimes, though, in the more severe attacks, the mucosa will be- come injected to such a degree that small ulcerations occur. In these cases the mucus is often stained or streaked with blood. Microscopically, are seen the bacillus coli communis, also the trichomonas intestinalis, and paramoecium coli, and occasionally the cercomonas intestinalis. We also find red blood corpuscles and leucocytes, and always large numbers of desquamated epithelioid cells, dotted about with fat globules and vacuoles. Symptoms. The onset is sudden and usually ushered in by an attack of cholera morbus, or by an attack of acute indigestion. Sometimes a more or less distinct chill may occur at the onset. Nausea and vomiting are not rare symptoms. The tongue has a moist coat at first but soon becomes dry. From the first there is diarrhoea. Pain is complained of over the entire abdomen, also tenesmus, and severe griping pains. The patient is extremely restless and can not get relief from a desire to stool. The bowel movements are at first free, and watery, or sero-sanguin- ous, but later on, contain only small quantities of mucus streaked or stained with blood, and have an offensive odor. A slight elevation of temperature usually accompanies this form, but, in more severe cases, it may reach 103 DIPHTHERITIC DYSENTERY. 245 degrees F. There is corresponding acceleration of the pulse, and the patient complains every few minutes of thirst. The stools, during the first day or two of the attack, contain, in addition to the above mentioned materials, small fecal masses (scybala). Sometimes during the course of the attack, the stools contain an excess of bile and cause intense burning while passing. The ordinary cases of acute catarrhal dysentery are self-limited, usually recovering in a week. Some are so mild that treatment is not sought. It must be remem- bered, however, that the cases which begin with mild symptoms may develop graver ones at any moment. Diagnosis. The diagnosis is very easy. The cramping pains, tenesmus, and frequent passages of mu- cus and blood are positively diagnostic. If, however, a case may be obscure, the microscope and proctoscope will at once clear it up. Prognosis. In most cases the prognosis is favor- able, but it is best to be guarded at all times in giving it. since some of the cases, which, at first seem quite mild, may terminate adversely. Ordinarily, though, the symp- toms will subside in a week, and the patient will recover rapidly. There is always rapid emaciation and weak- ness. Diphtheritic Dysentery. Definition. This is an inflammation, usually confined to the lower part of the colon, and rectum, but sometimes extending into the small bowel. It is accompanied by a croupous, or true diphtheritic exudation. It is one of the epidemic forms found in Japan, also in armies, in insane 246 DYPHTHERITIC DYSENTERY. asylums, and ships, or wherever large numbers of people are crowded together. Etiology. This form of dysentery is caused by the Bacillus Dysenteriae, discovered by Shiga in Japan (1897). Flexner and Strong encountered the same bacil- lus in one of the forms of the disease which prevails in the Philippines and Porto Rico. The bacillus is described by Shiga as being a short rod with rounded ends, and closely resembling the bacillus of typhoid fever. It pos- sesses slight motility. Flexner discovered that the bacil- lus ' i Is inactive to blood serum from typhoid fever cases, but reacts with serum from dysenteric cases to which bacillus typhosus does not respond." Shiga 's bacillus may be found within the body as late as one year after the primary infection. Pathology. The mucosa, if the attack is not severe, is coated over with a yellow exudate. Slight ulceration of the mucous membrane over the tops of the folds of the colon are seen. In severe attacks, however, all the layers of the colon are involved, and it appears greatly enlarged. The in- filtration is so great that extensive necrosis takes place. The mucous membrane over the entire colon presents a puffy or swollen condition, yellow in color. Large areas may slough en masse. Microscopically, this slough is found to consist of a fibrinous and cellular exudate coating over the mucosa. The glands of Lieberkiihn are destroyed, and some- times no trace of them is found. Symptoms. The symptoms are practically the same ig those of acute dysentery greatly intensified. The on- set is more severe. The chill is often present, and the SECONDARY DIPHTHERITIC DYSENTERY. 247 fever is high, running an irregular remittent course. The pulse is greatly accelerated, tormina and tenesmus are most severe. Delirium is common. Bowel movements may at first be loose and watery. Soon great quantities of sero-san- guineous discharges, containing bloody muco-purulent material and sloughs of variable sizes are passed. The distension of the abdomen is greater and pain is more severe. There is more rapid loss of strength. Diagnosis. The diagnostic points of most value are the character of the dejections, which may contain pseudo-membranes, severe symptoms, and the appear- ance of epidemics. The positive diagnosis is by the agglutination test. Complications. Complications in this form are en- countered more frequently. Perforations sometimes occur, and are almost inva- riably followed by peritonitis. Liver abscess is another grave complication. Nephritis, phlebitis, pericarditis, endocarditis, and pleurisy have also been noted. Recovery sometimes takes place, but usually after a more or less chronic course. Secondary Diphtheritic Dysentery. The lesions of this form are similar to those of the last described, but not so severe. The secondary, as the name implies, usually follows one of the acute, or chronic diseases, as pneumonia, nephritis, pericarditis, endocar- ditis, pulmonary phthisis, typhoid fever, and numbers of other varieties. 248 AMEBIC DYSENTEEY. Symptoms. The symptoms are sometimes not very noticeable. The griping pains and tenesmus are not very severe as a rule. The patient has about two to six loose bowel movements a day. Anatomically, the inflam- mation is very superficial, only the upper layers of the mucosa being involved. The inflammation may progress producing more or less necrosis. Very little blood is found in the stools. Prognosis. The patient will often perish. Owing to adynamia already existing, much resistance is impos- sible. Amebic Dysentery. Synonyms. Amebic colitis, amebic enteritis, amebiasis. Dysentery in this form is both epidemic and endemic in the tropical countries, especially India, Africa, and the Philippine Islands. In the United States sporadic cases are met with frequently. Osier says, his cases in the Johns Hopkins Hospital were almost exclusively amebic. It is very rare, indeed, that the writer is called upon to treat a case of the severe acute or chronic type in which he is unable to make a positive diagnosis of amebic in- fection by means of the microscope. This is the prevalent type of the grave chronic and relapsing cases of dysentery in this country, and many of the supposed diphtheritic dysenteries are of this origin. The microscope alone, however, can verify or refute this opinion. Etiology. This form of dysentery is caused by the entamoeba histolytica or the amoeba dysenteriae (Fig. 100). (Councilman and Lefluer.) AMEBIC DYSENTERY ETIOLOGY. 249 It is a type of protozoon, unicellular, and motile, sev- eral times the size of a red blood corpuscle. In structure Fig. 100. Amoeba Histolytica Schaud. A, young specimen ; B, an older specimen crammed with ingested blood- corpuscles; C, D, E, three figures of a living amoeba, which contains a nucleus and three blood corpuscles, to show the change of form and the ectoplasmic pseudopodia; n, nucleus; b, c, blood corpuscles. After Jurgens, from Allbutt's System of Medicine. the organisms have an outer colorless zone called the ectosarc or hyaloplasm, and an inner granular zone, the endosarc or endoplasm. Its nucleus is eccentrically situ- ated, and one or more vacuoles is present. This parasite is phagocytic in character, and may be seen to contain red blood cells, vacuoles, and other particles. It is easily mistaken for a large epithelial cell, or paramoecium, when not in motion. It is ten to fifty microns in size. The amoeba hystolytica multiples by segmentation, the nu- cleus and endoplasm dividing in such manner as to form 250 AMEBIC DYSENTERY ETIOLOGY. several embryo cells for the corresponding number of new cells. The old cell either dies or enters into the encysted state. After an uncertain period the cell wall bursts, and liberates the new ones. The mother cell, containing the daughter cells, may remain encysted for an indefinite Fig. 101. Amoeba Cell. A and B, living amoebae, showing changes of form and vacuolation in the protoplasm ; C, D, E, amoebae, showing different conditions of the nucleus (a); F, a specimen with two nuclei, preparing for fission; G, a specimen with eight nuclei preparing for multiple fission; H, an en- cysted amoeba containing eight nuclei ; I, a cyst from which young amoebae (al) are escaping; J, K, young amoeba free. After Casagrandi and Barbagallo from Allbutt's System of Medicine. AMEBIC DYSENTERY ETIOLOGY. 251 time. In this state it is much smaller than the ameboid form, and is non-pathogenic. There are two well recognized species of amebae, the kind above described, and the amoeba coli mitis (Fig. 101) which is occasionally found in healthy persons. This or- ganism is also found in other bowel affections. It is non- 1 phagocytic, twelve to thirty-six microns in size. Propa- gation is by gemmation or budding; a portion of the cell body being thrown out and then broken off, forming a new individual.* All authorties now agree that the bacteria of symbiosis, and other associated micro-organisms, have much to do with the pathogenicity of the amebae. I have noted that the cases presenting themselves dur- ing the summer or autumn usually show the more active and phagocytic amebae, or, more properly speaking, in those cases in which I have found the more active and' phagocytic amebae, I have also found the greater viru- lence. In making microscopic examinations of most cases the parasites are either very inactive or cease motility quickly, rendering necessary at times two or three exami- nations to make a positive diagnosis. In most cases the bacteria of symbiosis are quite numerous. The amebae are introduced into the intestinal tract through the mouth and stomach, but the acid gastric *After close observation, covering a great number of cases, the writer has become convinced that there exists a pathogenic amel which does not correspond exactly with the description above giver of the ameba hystolitica. This ameba is smaller, the hyaloplasm is not so distinct thougn its lighter zone is discernable and this hyloplasm or ectosarc can t seen forming pseudopods. This ameba is both granular and ( phago- cytic, and is often observed very active, hence in the writer s opin ion this ameba likewise is pathogenic. 252 AMEBIC DYSENTERY ETIOLOGY. juices prevent their propagation. They pass on into the colon to gain lodgment at favorite points, namely, the ilio- cecal valve, hepatic and splenic flexures, and especially upon the plicae transversalis recti. In most cases the in- flammation begins first in the rectum and extends upward by continuity. The writer has endeavored to explain the periods of exacerbation and amelioration of symptoms, in the fol- lowing ways : First. The entamoeba hystolitica is especially fond of feeding on the juicy sub-epithelial structures, and, in a given case, this particular crop or generation, within the plentiful surroundings, may become indolent and easily satisfied, and also less active in the process of sporula- tion. Second. The parasite may be in a state of encystation, during which period the amebae remain dormant or non- pathogenic until finally a different generation produces a more active and phagocytic type. Third. Because of the presence of a greater or less number of bacteria of symbiosis which, in the light of observation of most authorties, seem essential to the activity and virulency of the amebae. A further study of the problems of immunity may in the future yield information which will be of paramount importance in amebic dysentery, both in reference to the amoeba and the symbiotic bacteria. This disease is most often contracted through drinking water. Flies and other insects are possible means of transmis- sion. It can also be developed through contact. AMEBIC DYSENTERY PATHOLOGY'. 253 When making a microscopical examination of the feces for amebae, the following will be helpful to the inexperi- enced microscopist : Technique: Warm the slide slight- ly. Secure a small bit of the mucus from the stool and place upon the slide. Cover with a cover glass quickly, and press it gently until the material is thinly distributed. Examine at once with the one-sixth or the oil immersion objective. This should be done as rapidly as possible since the amebae retain motility for only a short time in temperatures, much lower than body heat. If now they can not be found, apply warmth by holding an electric light bulb to one side of the stage. They may then be seen. Never be positive that the amebae are not present though not found. They may be in a state of encystation in the tissues, and only after an acute exacerbation of the disease, will they be found. A still better plan, and the only accurate way, is to examine the scrapings of the ulcerated mucous membrane. This method should always be practiced when possible. The most important of the associated organisms, are the streptococcus, staphylococcus, bacillus coli communis, trichomonas intestinalis, paramoecium, cercomonas in- testinalis, lambia intestinalis, bacillus pyocyaneus, and others. Pathology. Pathological lesions are almost always confined to the rectum and colon, but occasionally the ileum may become involved. Appendicitis is quite common. The mucosa appears red and congested, and covered with mucus usually tinged with blood. The infiltration and edema now invade the submucosa. necrosis of the overlying mucous membrane takes place, 254 AMEBIC DYSENTERY PATHOLOGY. and the amebic ulcer is formed. This necrosed area may be oval or irregular in shape and appears to project over, the level of the mucosa. The amebae gain access into the sub-mucosa through the inter-glandular spaces and carry with them the asso- Fig. 102. Slough of Mucous Membrane Twenty-eight Inches in Length from a Fatal Case of Dysentery. Photograph of specimen from one of Jelk's cases. AMEBIC DYSENTERY PATHOLOGY. 255 elated organisms. Here they set up an active inflamma- tion, and produce ecchymosis and swelling of the glands. The number of the amebae in the sub-mucosa is great, since they prefer this juicy sub-epithelial tissue, no doubt because they find food more easily. When they get into the sub-mucosa their presence excites a reactive inflam- mation at once. It is important to note here that the bacteria of sym- biosis play a very important part in the inflammation just described. Necrosis now takes place in the inflam- matory area and sloughing follows. In grave and fatal cases this undermining process, so to speak, may become so extensive, and the congestion so great that large areas will necrose and slough. The writer has preserved one specimen of this character twenty-eight inches in length. (Fig. 102). The muscular coat of the bowel offers greater resist- ance to the amebae, so they seldom invade it. Occasion- ally, however, this undermining process will extend into the intermuscular tissue, and produce the same results as before described. In this way the larger and deeper ul- cers form. (Fig. 103). The involvement .of the rectum in one case was so ex- tensive that the new scar-tissue produced an almost com- plete stenosis. Higher up the ulcerations usually cover a smaller area. A sharp-edged, clean-cut ulcer results. This ulcer may involve the greater portion of the thick- ness of the wall of the bowel, but the undermining is not so extensive and the thickening which results lower down is not so marked here. One post-mortem revealed nine distinct perforations in the splenic flexure, which pro- 256 AMEBIC DYSENTERY PATHOLOGY. duced sudden death when the loose attachment of the omentum was broken by gaseous over-distension. Fig. 103. Edge of Intestinal Ulcer. (Toluidin-blue and eosin. Beck 1 inch, Oc. 3.) A. Mucous coat which projects over ulcer at f. B. Submucosa. C. Circular layer or muscle fibres. D. Tissues of mesocolon. E. Amoebae in dilated lymph spaces. Courtesy of Dr. H. F. Harris, Atlanta, Ga. The writer wishes also to call attention to certain spots and lines which he considers almost diagnostic when pres- ent. By careful examinations with the proctoscope small red papular spots may be seen dotted about among the already well denned ulcers. Perhaps on the following day the red spots will show a little white or yellow point of necrosis in its center. Upon the next examination an ulcer will be seen to have taken its place. AMEBIC DYSENTERY PATHOLOGY. 257 In another instance a few circinate or ring-worm-like lines in the mucosa, a picture which is not observed in other forms of intestinal infection, will be seen. These Fig. 104. Dysenteric Ulceration on the Valves of Houston. (After Tuttlc.) lines or ulcers are chiefly submucous, but sooner or later break into the undermined ulcer, and may then assume any shape. New lines will form, however, to tell the story. (Fig. 104). The writer has also observed small openings at points along the courses of these circinate lines leading to ex- tensive submucous ulcers. At other times the intestinal mucosa presents only a few circinate lines overlying the 258 AMEBIC DYSENTERY PATHOLOGY. sub-epithelial ulcers, while the remaining mucosa pre- sents a red granular appearance. In a few cases (unmistakably amebic) the disease ap- peared to be only a hypertrophic proctitis, or a procto- Isigmoiditis, and in others the mucosa appeared puffy or edematous. It is very probable in my opinion that some of these conditions were concomitant and due to associated condi- tions, especially collateral infections. Amebae have been found free in the peritoneal cavity, and in other parts of the body, especially the liver. Here, ; when unassociated with collateral organisms the para- sites are non-pyogenic. A true amebic, unassociated in- fection in the liver would mean simply that ; and not an abscess cavity filled with the most offensive pus, as is so often found. Perhaps in almost all cases amebae have .been conveyed into the liver, and, but for the fact that they were unassociated with pyogenic organisms, ab- : scesses would surely follow. Hepatic abscess complicates probably twenty per cent of all chronic amebic infections, liowever, exact statistics can not be obtained. Councilman found this complication in six out of eight autopsies. Strong and Musgrave in fourteen out of ninety-seven autopsies. Out of a series of twenty-five cases treated by the wri- ter in 1908, four were complicated by hepatic infections. In two of these cases the diagnoses were verified by ope- rations. In one a large abscess of the right lobe was found, and in the other, the right lobe was inflamed and firmly adherent to the omentum and hepatic flexure of the ^^R* ,4* PLATE II. Section of intestine just below ulceration. Toluidin-blue and eosin. Beck %, Oc. 3. In upper portion of the field a large vein is seen; the wall of the vessel which is nearest the ulceration is being infiltrated with small cells and is breaking down; both red and white cells and amoebae are seen within the lumen of the vessel. In the lower portion of the field many amoebae are seen, some in the tissues, and others in the lymph spaces and lymph channel. Courtesy of H. F. Harris, Atlanta, Ga. AMEBIC DYSENTERY SYMPTOMS. 259 colon. A cholecystitis was also present, and required drainage for six weeks. The infections may be carried into the liver in two ways : First, and most probable, .through the portal vein, which has often been found infected. (See Plate II.) Second, by transmission through the intestinal wall. Craig claims that the kidneys often present the lesions of acute parenchymatous nephritis. Symptoms. In the more virulent or malignant cases the onset is usually sudden, and may or may not be ush- ered in with a rigor. The attack is preceded by a period of malaise, often accompanied by constipation. An at- tack of acute indigestion often precedes this form of dysentery. The patient may have six to forty bowel movements during the first 24 hours, usually sero-sangui- neous in character. Prostration is early. By the second or third day considerable blood and pus begin to appear, the latter being very offensive in odor. Prostration in- creases with the further absorption of toxins. Tempera- ture usually rises to 102 to 103 degrees F., and is of the irregular remittent type. Delirium may be pronounced. General abdominal pain and tenesmus with tympanites and tormina are prominent. The facies abdominalis de- note suffering and anxiety. The nose is pinched and the upper lip is retracted, and the condition now is a grave one. The thighs are flexed upon the abdomen and legs upon the thighs in such manner as to relieve pressure upon the abdominal viscera. Considerable tenesmus pre- cedes and accompanies all bowel movements and may fol- low for several minutes, though as a rule a greater or 260 AMEBIC DYSENTERY SYMPTOMS. less relief follows the passage of only a small amount of bloody mucus. Later the more offensive discharges, con- taining greater quantities of mucus, pus and blood, with perhaps muco-fibrinous casts, or mucous membrane sloughs, indicate necrosis. The above symptoms are soon followed by delirium, subnormal temperature, rapid, feeble pulse, clammy per- spiration, glazed skin, collapse and death. If, after the sloughs are passed the patient survives the sepsis and tox- aemia, and healing of the ulcers follows, the process is a slow one. These ulcers are finally filled with granulation tissue and fibrinous material, which contract, causing more or less stenosis. The symptoms of sepsis and tox- aemia from the absorption of necrotic material and toxins very gradually diminish until the patient is able to resume his regular occupation. The following case reports will be helpful : Case 1. Name, Dr. - -; age, 36 years; race, white; occupation, physician; family history, negative; previous state of health, good, until six months previous, during which time he suffered a rapid decline. Symp- toms : Lost thirty or forty pounds in weight ; complained of slight colicky pains over course of colon ; troubled with loose fermentative diarrhoea; inactive liver; coated tongue; temperature 992-5 F. ; pulse, 60; skin, dry and muddy ; slight tenderness on pressure over cecum, hepa- tic and sigmoid flexures; pronounced melancholia, insom- nia, and malaise were present. Had not noticed passages of mucus from bowel but spoke of a very offensive odor. Proctoscopy revealed a considerable quantity of san- gumo-purulent mucus in the rectum, and the rectal nm- AMEBIC DYSENTERY SYMPTOMS. 261 cosa was covered with same, mixed with some light brown fecal material. Small circinate lines and punctate ulcers were seen on the rectal walls and valves of Hous- ton. A mild granular procto-sigmoiditis was noted. Mi- croscopic examination revealed entamoebae histolyticae, phagocytic and associated with bacteria of symbiosis, trichomonas intestinalis, paramoecia, and others. Diag- nosis, Amebic Dysentery. Case 2. Name, Dr. - ; age, 53 years; race, white; occupation, physician; family history, negative; previous state of health, good, until 23 years of age, since which time he has never been well. Symptoms: At the age of 23 suffered a very severe attack of dysentery and for a long time, hope of recovery was despaired of. Later a change of climate seemed to contribute to his slow but apparent recovery. After returning home suffered a re- lapse. Since that time has suffered abatement and accele- ration of symptoms ; alternating attacks of diarrhoea and constipation; suffering now from profound melancholia and insomnia with suicidal inclinations. Temperature, sub-normal; pulse, 65; tongue, dry and coated heavily, round and thick; skin, inactive and muddy; liver, en- larged, extending three inches below costal border and tender, probably the seat of a large abscess. Pain on pressure over entire course of colon, especially over cae- cum, hepatic and sigmoid flexures. Furunculosis (Sta- phylococcic) over entire body; atonia gastrica with dilata- tion ; kindeys, normal. Doctor William Krauss' report: "Proctoscopy rectal walls very much thickened, scarred and stenosed, this latter condition observed at recto-sigmoid juncture 262 AMEBIC DYSENTERY SYMPTOMS. also; red granular hypertrophic recto-sigmoiditis. The characteristic ulcers, previously referred to, were found beneath a coating of offensive blood-tinged mucus, which was mixed with pus. Microscopic examination revealed large active phagocytic amebae histolyticae, colon ba- cilli, trichomonas intestinalis, cercomonas intestinalis, and other symbiotic bodies in great numbers. The blood examination, made by Dr. Krauss in this case shows the following: 3,940,000 red cells, 75 per cent hemo- globin, 13,700 white cells, of which 74 per cent poly- nuclears and 3.3 per cent eosinophiles. The opsonic in- dex failed. The bacteria isolated from the pustules were staphylococcus albus and a single colony of aureus. I regard the blood condition to be one of secondary ane- mia with mild coccus infection, and the moderate eosino- philia is probably due to the intestinal condition." The furuncles were healing nicely when I last saw the patient, and he expressed himself as feeling greatly im- proved. Diagnosis, Amebic Dysentery. The writer looks with suspicion upon any case of dys- entery or diarrhoea, recurring or relapsing, which has failed to respond promptly to treatment. Dysentery and diarrhoea are not essential symptoms of the existence of amebiasis, though this is contrary to the generally accepted theory. In many cases the patient will complain of recurring diarrhoea which has existed for months or years. These attacks are accompanied by passages of mucus, usually considerable in quantity, and occasionally stained with blood. The patient complains of almost constant pain or discomfort in the left iliac AMEBIC DYSENTERY COMPLICATIONS AND SEQUELAE. 263 fossa, and, when the lower rectum is the seat of consider- able ulceration, pain at the end of the spine and in the rectum is felt. This symptom is momentarily relieved by evacuations-. A case from the Mississippi Delta, reported by me to the American Proctologic Society, had most violent symptoms from the onset. On the fifth day a large slough of mucous membrane (see Fig. 102) was passed en masse Thirty- six hours later the patient died. Most of the chronic cases will give a history of having lost much weight, perhaps twenty to fifty pounds. Many have symptoms of interest to the stomach specialist, and to the neurologist. Complications and Sequelae. These are very nu- merous indeed. Of 1537 cases of diarrhoea in Egypt only 406 were un- complicated. Hepatic abscesses were found in six out of eight autop- sies by Councilman. In four of these they were multiple. Strong and Musgrave found hepatic abscesses in 14 out of 97 cases. The writer, as previously stated, found liver infections in four out of twenty-five cases. The vermiform appendix has been found to be involved in fully ten per cent of chronic cases by the writer. Among the other complications most frequently occur- ring are, perforations, extensive sloughs, hemorrhages, fibrosis of the valves of Houston, rectal stenosis, adeno- mata recti, cholecystitis and jaundice, peri-rectal abscess, hemorrhoids, fistula, pneumonia, pulmonary abscess, pleurisy, bronchitis, nephritis, portal thrombosis, cere- bral and meningeal emboli, gastritis, atonia gastrica, mel- 264 AMEBIC DYSENTERY DIAGNOSIS, PROGNOSIS. ancholia, which is often profound, and in two recently treated cases extensive skin lesions were encountered. In one of these a microscopic examination revealed the pres- ence of the staphyloccoccus albus and aureus. Statistics from all sources show that perhaps twenty per cent of all cases are complicated by hepatic infection. The right lobe is most often involved. Perforations may occur along the course of the colon at any point between the rectum and appendix. Perf ora- tive appendicitis has been noted. Perforation occurred in 85 out of 580 cases selected by Beranger and Feraud. Stenoses have been observed in a large per cent of chronic cases, usually in the rectum and sigmoid. When fibrosis of the rectal valves is observed, it is a grave ob- stacle to the complete cure owing to interference with drainage and local treatment : Hemorrhoids, though frequently noted, are not serious complications as a rule. The other complications mentioned above should be borne in mind and treated when they occur. Diagnosis. This is rendered easy by means of the microscope, all doubt being removed by finding the en- tamoebae histolyticae in the stools, or in the material curetted from the ulcers in the rectum and sigmoid. Prognosis. The prognosis in amebic dysentery is likewise much graver than in the acute catarrhal form. It may be said to depend upon several things : First The previous state of health of the patient. Second The hy- gienic condition of the patient's surroundings. Third The efficiency of the treatment employed. AMEBIC DYSENTERY TREATMENT. 265 In the United States the total number of deaths from all forms of dysentery in 1850 was 20,556, a per cent of 6.32 of the total mortality. In 1880 out of 756,893 deaths, 10,825 were from dysen^ tery. Treatment. The treatment of dysentery will be dis- cussed under the heads, (a) Prophylactic, (b) Dietetic, (c) Eemedial and Operative. Prophylactic. Strict attention should at all times be given to the hygienic condition of surroundings. Re- move and avoid as far as possible the causes of dysen- tery. Cases should be isolated when it is possible to do so. All excreta should be carefully disinfected and de- posited where the water supply will not be contaminated. The country practitioner, living where there is no sewer- age system, should never neglect to caution those attend- ing the patient to deposit the excreta in a hole dug for the purpose as far removed from the water source and garden as possible, after first disinfecting thoroughly. If a person, knowing the danger, were to deposit the excreta of a dysenteric patient in a garden, it would be inexcusable. The writer has, however, seen this done by some who had never suspected danger in so doing. In the country, and in small towns, without sewerage, little closets are usually found in or near the gardens, and are often made sources of fertilizing material for the growth of vegetables. It is the duty of the physician to educate his patients in regard to all dangers resulting from such gross unsanitary pratices. Wells and cisterns are contaminated much more often than the average lay- man suspects. When the source of the drinking supply is 266 AMEBIC DYSENTERY DIET. at all questionable, the water should be boiled before drinking. Over-crowding and poor ventilation should be pre- vented. The care of the room occupied by the patient is important. Unnecessary furniture, such as curtains, rugs, carpets, etc., should be removed. Disinfectants should be used at regular intervals. Linen should be changed daily. Bed pans, commodes, drinking cups, etc., should be disinfected thoroughly. Diet. Diet is as important as any other matter in the treatment of dysentery. During the period of acute intes- tinal symptoms it should consist of boiled, or perhaps better still, peptonized sweet milk, buttermilk, whey, egg whites, light animal broths, peptonized beef juice, barley water, and perhaps one of the standard malted milk foods for infants. In all cases select a diet which is digested as far as possible in the stomach, and which has little waste. Food is best given at intervals of one to two hours in acute cases. Plain sweet milk may be diluted with barley or rice water, lime water or Vichy, if imperfectly digested. During convalescence in all forms of dysentery and for chronic cases, the writer prefers butter milk, peptonized or pasteurized sweet milk, whey, and eggs. In some cases tender portions of turnip tops, mustard, and spinach have been given, and were relished by the patient. It is, how- ever, questionable as to the propriety of giving the pa- tient much vegetable diet. In cases of amebic dysentery the writer is especially partial to a diet of milk and egg whites. The eggs may at times be prescribed in large quantities, from eight to: AMEBIC DYSENTERY REMEDIAL TREATMENT. 267 fifteen per day. They can be ordered raw, mixed with milk, or in the form of egg-albumen. The latter is made by stirring the white of one egg into a glass half full of crushed ice, then flavor with orange juice and sweeten. Diffusible stimulants, such as champagne, sherry wine, or whisky, may also be added to the egg mixture when cardiac weakness and adynamia are present. The albumen may also be mixed with sweet milk, or sweet milk with lime water in the form of a milk-shake, to which may be added the alcoholic stimulants, if indi- cations exist. Butter-milk is an especially favorite diet. Its acid properties make it desirable. The articles of diet which are contra-indicated are all dishes highly seasoned with pepper, cinnamon, nutmeg, etc. Vegetables, especially the raw varieties, pork, salt meats, veal and fish, saccharine foods, and fried foods, nuts, oatmeal and fruits, should also be interdicted. Remedial. The medicinal treatment of dysentery is a most interesting subject. A great number of so-called specifics, and much praised remedies, have been handed down to us, but most of them have proven so unsatisfac- tory that it is no surprise that most of the present day suggestions are greeted with a certain amount of skepti- cism or personal prejudice. The systemic treatment as a cure for dysentery is erroneous. It is a local disease and therefore requires local treatment. This is certainly true with reference to immediate pathology, but other remote pathological conditions may require constitution- al treatment. The ameba is a very low form of organic life and is very easily killed or rendered inert. The fact remains, 268 AMEBIC DYSENTERY REMEDIAL TREATMENT. however, that the parasites are embedded in the tissues in such vast numbers as to make their destruction diffi- cult. Certainly any chemical which is given by mouth, after passing through the stomach and small intestines, can possess little parasitic effect when it reaches the low- er colon, sigmoid flexure, and rectum. Therefore, our chief reliance must be placed in local applications, which are used for the following purposes, namely: That of washing away the pus, mucus, and debris, and, at the same time, the amebae and other pathogenic organisms. Also that of antisepticizing the bowel contents and walls, that the further growth and development of the patho- genic organisms will be inhibited. It is also important to remember that the remedies se- lected should be those which will destroy the greatest number of organisms beneath the lining membrane of the bowel without destruction to the tissues themselves. In the earlier stages of acute dysentery the patient should be put in bed and absolute quiet enjoined. Chill- ing draughts of air are to be cautiously avoided since they are apt to increase the congestion of blood toward the internal viscera. Bathing the patient with warm water, vinegar, or alcohol will often give great comfort by relieving the burning sensation in the skin. The peri- anal region should be sponged frequently with an anti- septic wash, such as a mild boric acid and formalin solu- tion, and dusted with some mild antiseptic powder, as equal parts of boracic acid and aristol. An ointment of similar composition may be used instead. Application of hot or cold to the anal region will often relieve the burn- ing and tenesmus in the lower rectum. The hot hip AMEBIC DYSENTERY TREATMENT LAXATIVES. 269 baths also have been very helpful in relieving this con- dition. In the more severe cases the constant application of ice bags over the left iliac region gives comfort. Hot fomentations are sometimes to be preferred but in the majority of cases, the ice bag is better. The severe griping and tormina are relieved quite readily by hot turpentine stupes or by large flax seed meal poultices. These may be used just as frequently and for as long a period as needed. Laxatives. Occasionally absolute rest and strict. diet are all that is needed to relieve the patient, but it is in most cases best to administer some mild laxative to re- move the contents of the bowel, which act as both me- chanical and chemical irritants. Castor oil and magnesium sulphate, to the latter of which may be added dilute sulphuric acid, are the most popular remedies for this purpose. The salines, by their hydrogogic action deplete the inflamed mucosa and wash away many of the infecting micro-organisms. It must be remembered, however, that all purgatives act as irri- tants to the intestinal mucous membrane in a greater or less degree, and their use must be guarded with judg- ment. In some cases they would be harmful. If there has been much diarrhoea and the stools are copious and thin, purgatives are contra-indicated. When to repeat a purgative is another question that should be considered with care. Often much harm is done in this way. Calomel, or calomel with ipecac, is often ordered in small doses for a dry, furred tongue, and inactive liver 270 AMEBIC DYSENTEEY LAXATIVES. with foamy acrid discharges. Our aim in giving calomel is not only that of producing the antiseptic action of bile, but also by depleting the liver, to relieving the portal congestion; and this in turn, the congestion of the veins about the rectum. The severe griping pains and tenes- mus, the diarrhoea, and restless condition of the patient, when present, must be relieved or the outcome will be rapidly adverse. Opium is the remedy, either in the form of Dover's powders, paregoric, laudanum, or morphine. This last is no doubt the most popular form of the drug and is best used hypodermicaliy. The dose should be just large enough to keep the patient quiet and to relieve the suffering but never sufficient to produce narcotism. It must not be forgotten that opium may do great harm in some instances. If nature is attempting to throw off the putrid contents of the bowels in large, liquid stools, we should not give opium, for in so doing we are inter- fering with her efforts to relieve the condition. A large number of intestinal antiseptics have been giv- en internally for dysentery, the principal ones being cal- omel, lead acetate, zinc sulphocarbolate (in one-half to three-grain doses), salol, guaiacol carbonate, bichloride of mercury (dose, grains 1-1201-50), and acetozone. These are all, however, given by the writer with a cer- tain feeling of uncertainty. Those cases which begin with symptoms of cholera morbus, with nausea and vomiting, and subnormal tem- perature, call for hypodermic injections of morphine sulph. gr. V s , and atropine sulph. gr. 1-150. To control nausea may be given acid carbolic and tr. iodine, of each one minim well diluted, by mouth. This is followed bv AMEBIC DYSENTERY REMEDIAL TREATMENT. 271 calomel, grs. Vs-^A and salol, grs. 2 to 5, with just a sufficient amount of hot water to administer same. In other cases cocaine hydrochlorate (gr. Vs-^) may be given, and, where there is much depression, warm enemas of normal salt solution may be given, or this may be given by hypodermoclysis. The effect is a dilution of the toxines and a reaction. A mustard plaster or hot turpentine stupes over the epigastrium are beneficial in these cases. If the temperature and pulse are not sub- normal, the tormina, tenesmus, and burning can be al- hiyed by enemas of cold water, the temperature of which should be regulated to suit the case. When there is marked irritability of the rectum, the following suppository should be inserted before injec- tions are made: J^ Cocaine hydrochlorate, Ext. stramonium, Ext. belladonna each gr. ss. 01. theobromae Q. S. M. et. ft. in suppositories No. 1. Sig. Hold the suppository in the anal canal about one minute, then press into the rectum with the index finger. Kartulis claims that he found ipecacuanha to have an almost specific influence upon dysentery. His method of administering this drug was to give a one-half grain injection of morphine hypodermically and place a mustard plaster or turpentine stupe over the epigastrium. After half an hour twenty grains of pulv. ipecac was given, and this dose was repeated every half- liour to one hour until an ounce had been given. 272 AMEBIC DYSENTERY INTERNAL MEDICATION. Another method of giving this drug : Put 2 to 8 grams ( l /2 to 2 drachms) in 500 grams (1 pint) of water and let stand two hours. This solution is filtered off and con- stitutes the first dose, or this is at times divided into two or more doses. According to Kartulis, this always pro- duces emesis and diarrhoea, but, after a second or third infusion, which is made from the remaining portion of the powder with the same quantity of water, has been tak- en, the vomiting and purging become less frequent. If, after the third day's treatment with these infusions, the patient has not improved, another series of infusions with a fresh supply of ipecac should be given. The writer has mentioned this treatment only to con- demn it. It has been known to produce death, and does Fig. 105. Instruments, Etc., Required in the Office Treatment of Dysentery. AMEBIC DYSENTERY INTERNAL MEDICATION. 273 not cure the disease. In all cases it is a cardiac depres- sant and lowers the physical resistance of the patient. It is a violent intestinal irritant. The powdered drug has also been found impacted in fatal perforating ulcers of the bowel. To my mind, therefore, its administration in this disease, by this method, is dangerous, adding in- sult to injury. For the acute catarrhal type the elimination of irritat- ing substances and free exosmosis obtainable by the ad- ministration of epsom salts, and enjoined rest in bed, with abstinence from all but the blandest forms of diet, will often suffice. In these cases, however, the injection of tepid water, containing to each quart, gtts. x to xx of formalin, and 1 tablespoonful of boric acid, may be necessary. This is often followed by the same quantity of cold water, or by the injection of 1 or 2 ounces of olive oil and one scruple of bismuth subnitrate. These injec- tions can do no harm and are surely destructive to the life and propagation and pathogenic properties of the infecting agent. If the symptoms do not abate, and the patient does not obtain marked relief within the first few days of the use of the above described treatments, pathology may be present which may require other forms of local treat- ment in the nature of topical applications. A subacute catarrhal condition may supervene in which an astringent and antiseptic treatment will be required to complete a cure. For this purpose may be used the in- jection of a tannic acid solution, one drachm to a pint of water, followed by the introduction of a suppository containing: 274 J-AMEBIC DYSENTERY LOCAL TREATMENT. I? Ext. belladonna grs. V 2 Ext. stramonium grs. i/. Aristol grs. 5 Ol. theobroma, Q. S. M. et. ft. in suppository, No. 1. Or the following ointment: I> Ext. belladonna grs. y 2 Ext. stramonium grs. !/> Aristol grs. 5 Liquid albolene, Q. S. M. et. ft. in ointment. Fig. 106. The Jelks Soft Rubber Recurrent Recto-Colonic Irrigating Tube. Courtesy of Dutro & Hewitt, Memphis, Tenn. If the disease assumes one of the more virulent types, and if the ulceration is extensive, still more radical meas- ures should be sought in the high irrigation with the for- malin boric solutions. These, if possible, should be given AMEBIC DYSENTERY LOCAL TREATMENT. 275 through a recurrent tube (Fig. 106), since by this means only can a large quantity of the solution be used without distending the inflamed and ulcerated bowel to a painful or perhaps dangerous degree. Four to eight quarts of this solution are usually re- quired for one irrigation. Some authorities are partial to the use of quinine so- lutions (1-5000 to 1-500) in cases of amebic infections. Among the advocates of this drug are Musgrave and Strong, and Osier. H. F. Harris, of Atlanta, says : "I used this treatment with great persistence in some of my earlier cases, but not in a single instance was there the slightest perceptible result." "Injections of 1-100 to 1-300 watery solution of bi-sul- phate of quinine were somewhat beneficial in one or two instances." My own experience with these injections is in accord with that of Dr. Harris. The use of formalin solutions in the strength of 1-500 to 1-1000 have in the writer's hands afforded the best re- sults. My study of the effects of this chemical has extended over a period of ten years. I have relied not only upon clinical results obtained, but also upon the microscopical observations in demonstrating the efficiency of formalin. After only one or two injections with these solutions I have been unable to find any living organisms in the bow- els for hours afterwards. This it was observed was not the case when other so- lutions were used. 276 AMEBIC DYSENTERY LOCAL TREATMENT. Eapid healing of the ulcers was always noted while continuing the irrigations of the formalin in the above mentioned strengths. To be certain of the effect of this drug, its use was discontinued for the time being, and such irrigations as plain water (warm or iced), normal salt, and quinine solutions, were substituted. In every instance the ulcers reformed, and both amebae and bacteria of symbiosis were found again in the microscopical examinations. Upon returning, however, to the formalin irrigations these micro-organisms disappeared and the ulcers began the process of repair. Thus the writer has concluded that this chemical, judiciously used, is really the most effective in the destruction of the amebae and associated Fig. 107. Exaggerated Sims' Position Showing Method of High Irrigation of Colon Through Jelks' Recurrent Tube. AMEBIC DYSENTERY LOCAL TREATMENT. 277 organisms, and most valuable in the treatment of dys- entery. The injection of olive oil and bismuth almost instantly relieves the painful effects of these solutions. The dangers of over-distension of an inflamed and ulcerated colon are difficult to over-estimate. To avoid this the writer has devised a double or recurrent colon tube, made of soft rubber, and constructed in such man- ner as to facilitate its introduction through the rectum, into the sigmoid and descending colon. The tube, hav- ing been properly inserted, it is an easy matter to change the position of the patient, and by so doing irrigate the entire colon. (Fig. 107). In some instaiaces the tube is obstructed by the rectal or recto-sigmoid valves, which may necessitate its intro- duction through the sigmoidoscope or proctoscope. In chronic cases especially has this difficulty been encoun- tered, since in these a fibrinous infiltration of these struc- tures often exists, rendering- almost impossible the use of an ordinary rectal tube. To ascertain whether or not the tube has coiled in the rectum, the operator can intro- duce the index finger, well annointed, with the lubricant given below. After several unsuccessful attempts have been made the proctoscope should be introduced and the tube inserted through it, as is shown in Fig. 108. A lubricant of the following formula is preferred by the writer : K Tragacanth Powder (Best) grs. 384 Phenol m 240 Glycerine oz. 2 Aqua Dist Q. S. ad. qt. 1 278 AMEBIC DYSENTERY LOCAL TREATMENT. M. Sig. Shake up gum with enough alcohol to make thick paste. Add acid and glycerine. Shake well and add water all at once. Agitate vigorously. Fig. 108. Position of Patient for Proctoscopy, Proctoscope Introduced to Facilitate the Introduction of the Colon Tube. CHRONIC OK SECONDARY AMEBIC DYSENTERY. 279 Dr. Louis LeRoy, of Memphis, lias suggested the use of phenol sulphonate of copper solutions for the colon irrigations. The writer has used this chemical in the treatment of a number of cases but is unable to state its exact degree of efficiency. It is a very powerful parasiticide and its use is advised alternately with the formalin boric solution. The strength of the copper solution is 8 to 10 grains to each quart of sterile water. Ichthyol (10% solution) applied locally to the mucous membrane, or gauze, saturated with the same solution, packed in the rectum, has seemed to exert a beneficial effect. It is well to mention here that an antidysenteric serum has been very highly recommended in the treatment of the malignant bacillary type of dysentery. Chronic or Secondary Amebic Dysentery. AH sub-acute or chronic cases of dysentery depend for their symptoms upon an ulcerated and inflamed condi- tion which will not yield to treatment. These cases have exacerbations and amelioration of symptoms. They often complain of constipation, which may extend through a period of weeks or even months. It is in these sub-acute and chronic cases that the procto- logist is most often consulted. Such remedies as nitrate of silver, grains 30 to 60 to an ounce of sterile water, or a 20% solution of argyroi are applied after first cleansing and antisepticizing the rectum and sigmoid with pledgets of cotton wrung out of hot formalin' boric solutions. (See Fig. 109.) 280 CHRONIC OP, SECONDARY AMEBIC DYSENTERY. A 30% solution of lactic acid has also been used to cauterize the ulcerative areas. Fig. 109. Method of Application of Silver and Other Solutions to the Ulcerated Surfaces of the Rectum and Sigmoid. CHRONIC OK SECONDARY AMEBIC DYSENTERY. 281 After these applications have been made the bowel is sprayed with some neutral or alkaline solution to neutral- Fig, no. Method of Spraying Rectum and Sigmoid, With Solutions and Also Insufflating Mucous Surfaces With Antiseptic Powders. 282 CHRONIC OE SECONDARY AMEBIC DYSENTERY. ize the excess of the silver or other solution used. (See Fig. 110.) The bowel surfaces are then dried. Now the insuffla- tion of some non-toxic antiseptic powder such as equal parts of boric acid and aristol is advised. The symptom of iodism is an unpleasant one and may be readily produced by the instillation of drugs contain- ing iodine into the rectum. Because of this, these rem- edies, such as aristol, bismuth-formic-iodide and iodo- form have appeared most effectual when used just to the point of tolerance. When the amebic infection has become very chronic, or has extended into all parts of the colon beyond the use of the local measures just described, appendicostomy should be performed and the same irrigations practiced through the appendiceal stump. The water is allowed to pass out through the rectum into the catch basin. This plan of treatment was first advised by Dr. E. A. Corsons, of Savannah, Ga. In 1898 Dr. H. F. Harris stated that some years be- fore Dr. Corsons had made this suggestion to him. Irri- gations of the bowel with hydrogen peroxide through the artificial opening, thus established, were also advised. About the year 1901 Dr. Robert Weir, of New York, while performing a colostomy for amebic dysentery, an- chored the appendix and irrigated through the stump with a saline solution. Shortly afterward Dr. Meyer, also of New York, per- formed a similar operation. Dr. Tuttle, of New York, conceived the plan of allow- ing the appendix to remain undisturbed after anchorage CHRONIC AMEBIC DYSENTERV SURGICAL TREATMENT. 283 for a sufficient time (three or four days) to establish ad- hesions about the proximal end before cutting away the distal portion, and using the appendiceal stump lumen through which to irrigate with the desired solutions. The writer has practised this latter method and irri- gated the colon with formalin boric, copper phenol-sulpho- nate and quinine solutions with most gratifying results. It was observed, however, that the irrigations alone did not effect a cure. Topical applications (per sigmoido- scope or proctoscope) were in all cases used in conjunc- tion. Dr. J. A. Crisler, of Memphis, in 1906, advised the an- chorage of the appendix in a small stab wound below the high incision, which is made with the view of inspecting the liver and gall bladder. In two chronic cases the writer was forced to perform rectal valvotomies on account of obstruction to drainage, and to the insertion of the proctoscope or even the tube beyond the valves, which were tightly stretched across the lumen of the rectum. This operation will rarely be found necessary. The writer here wishes to acknowledge with thanks val- uable assistance rendered by Dr. H. P. Conley in the preparation of this chapter. 19 CHAPTER XIV. PROLAPSE OF THE RECTUM IN CHILDREN. Prolapsus Recti, or prolapse of the rectum, is the de- scent, with or without protrusion, of one or all of the coats of the rectum, uncomplicated by any other diseased con- dition. Prolapsus aui is usually understood to mean the descent and protrusion of either the mucous membrane alone or all of the coats of the anus and lower end of the rectum outside of the anal aperture. Prolapse may be either partial or complete. Partial prolapse meaning that condition in which the mucous membrane alone protrudes; complete prolapse describ- ing the descent of all of the coats of the rectum. The complete variety is divided into three varieties, accord- ing to the degree or extent of the prolapse. Prolapse of the first degree is the condition in which the prolapsed portion begins at the anal margin, and the mucous membrane covering it can be seen to be continu- ous with the surrounding skin, there being no sulcus sur- rounding it. In complete prolapse of the second degree, it will be found that the descent begins at some point in the rectum above the sphincter and is protruded through the anal orifice, being telescoped as it were, through the non-affected portion below. In this variety a distinct 284 CLASSIFICATION. 285 sulcus can be made out between the prolapse and the margin of the anus. Fig. 111. Prolapse of the Rectum Third Degree. (Made from a photograph of one of the author's cases.) This shows the prolapsing rectum descending to the anus but not protruding. Prolapse of the third degree may begin either in the upper portion of the rectum or even in the sigmoid flex- ure. In this variety the rectum, and even the lower por- tion of the sigmoid, may descend into the lower rectal cav- 986 ETIOLOGY. ity, but .as a rule does not protrude from the anus. This variety is also known as concealed prolapse. (Fig 111.) Inasmuch as the limitations of this work does not in- clude those conditions whose relief requires surgical op- erations under general anesthesia for their relief, none of the conditions mentioned above will be treated, save the condition most commonly seen by the general practi- tioner prolapse of the anus and rectum in children. The most frequent variety seen in children is that known as the partial or incomplete, and it consists of an ever si on of the anal canal, carrying with it the mucous membrane covering the lower end of the rectum. It is a condition amenable in the vast majority of cases to non-surgical measures, when seen early and treated with patience and persistence. Etiology. It is brought about most frequently by severe prolonged or undue straining efforts on the part of the child. Such diseased conditions as the pres- ence of a rectal polypus, hemorrhoids, foreign body in the rectum, hard constipated stools, pin worms, stone in the bladder, phimosis, diarrhoea, excessive coughing or sneezing, accompanied by weakness of the sphincter mus- cle are responsible at times, but most common of all is the prolonged straining efforts at defecation. The practice so commonly in vogue among moth- ers in their efforts to train their children to regular habits of defecation has been responsible in the majority of cases for the production of prolapsus recti. The little patient is placed upon the toilet vessel or chair, and is soon made to realize what is expected of him. Sitting in the semi-squatting position which is most conducive to the emptying of the rectum, even of its own mucous SYMPTOMS DIAGNOSIS. 287 membrane, for half an hour; or even all the morning (as has happened in some cases which have come under the author's notice), the little one using all his efforts in order to accomplish his daily duty, gradually brings about a separation of the mucous membrane of the rec- tum, with accompanying protrusion from the anus. In other cases, through extraordinary efforts of the ab- dominal muscles, the mesentery of the sigmoid becomes elongated and an intussusception of the upper rectum and lower sigmoid takes place. Protrusion of the prolapsed bowel is very rare in this instance, and a condition known as concealed prolapse is produced and often goes undiag- nosed for a considerable period of time. From an ana- tomical point of view, the straightness of the sacrum in children offers less support to the rectum than in adults, and in children who have been suffering from wasting diseases, the parts become so relaxed that practically all support is taken away from the rectum. Symptoms. "When the rectum prolapses in children, it appears rather unexpectedly. After a more or less long period of time, in which the "training" of the child has been going on, the mother is surprised, some fine day, by the appearance of a ring of red or purple hued membrane surrounding the anus, the size depending up- on the amount of rectum prolapsed. The longer the pro- lapse remains outside the rectum, the more purple hued it becomes from the interference with the return circu- lation on account of the contraction of the sphincter. Diagnosis. The diagnosis is very simple ; in fact, self- evident. The appearance of a ring of soft, velvety mucous membrane protruding from the anus, is indicative only 988 DIAGNOSIS TREATMENT. of one condition, that of prolapse. A polypus would be differentiated by its rounded form, harder consistency and the presence of a pedicle behind the protrusion ex- tending into the anus. Hemorrhoids, which are rare in children, would be gradual in onset ; would be of firmer consistency, forming separate masses, and would not ex- hibit the peculiar red or purplish appearance of prolaps- ed mucous membrane. On each succeeding occasion, when the bowel is protruded, more of the mucous mem- brane comes down, and in aggravated cases the entire rectum may be protruded. Treatment. When the protrusion first makes its ap- pearance it may be reduced in the following manner : The child is placed on its mother's lap with the buttocks raised considerably higher than the head. A compress soaked in ice water placed against the prolapse will often be all that is necessary. Gentle pressure will in a few minutes, in most cases, cause a return of the prolapsed portion. Oftentimes simple digital pressure of one side of the prolapse while the buttocks are separated with one hand, and steady pressure made with the fingers of the other, will suffice. The other half is then treated in like manner. Where the prolapse has remained outside long enough to become swollen, oedematous or congested, and the sphincter has contracted upon it; it will often be very difficult to return the prolapse unless the sphincter has been relaxed by the injection of a local anesthetic. In order to relieve the congestion and shrink the blood ves- sels, the employment of compresses, soaked with one to one thousand solution of adrenalin chloride and applied TREATMENT NON-OPERATIVE. 289 with firm pressure to the protrusion has in the author's hands, been found extremely satisfactory. The blood ves- sels become constringed and the mass much reduced in size, and reduction is comparatively easy. "Whenever pressure is used in this region, it should be firm but gentle, as it would be very easy to do ser- ious damage if the manipulation were rough or violent. Wrapping dry absorbent cotton around the index finger and pressing firmly against the prolapse and in the di- rection of the rectal canal, will often return a prolapse with ease. The finger is withdrawn in a twisting manner so as to allow the cotton to remain in the rectum, from whence it is passed with the next stool. If the child's habits are corrected, the bowel, in many cases, will not protrude again. In cases, however, where the protrusion recurs, a definite line of treatment must be undertaken in order to relieve the tendency to chroni- city of the condition. Any exciting cause, such as stone in the bladder, phimosis, pin worms, polypus, foreign body in the rectum, etc., must be relieved by proper sur- gical measures. If the case is due to constipation, the child's dietary should be looked into and corrected. Where the case is one, however, where the prolapse has been brought upon by the prolonged sitting at stool, with its coincident severe straining efforts, this method of training must be dispensed with. The child must be made to move its bowels in the recumbent position, either lying on its back or side, preferably the latter. It must not be allowed to have movements in the sitting posture while under treatment. The administration of white pe- troleum oil or liquid albolene, suitably flavored, in doses 290 CONCEALED PROLAPSE. varying from ten minims four times a day in an infant, to a teaspoonful for the child of five or six years of age, should be resorted to in order to keep the stools soft and the intestinal canal well lubricated. It is important after the bowel movements to strap the buttocks together with strips of adhesive plaster ; and in some cases it may be advisable to keep a pad made of absorbent cotton, wrapped with gauze, firmly against the anus. This treatment will be very successful if persisted in long enough. The author would advise two months as the average length of treatment in the average case. Any tendency towards diarrhoea should be immediately look- ed after, and the dietary cause for it discovered and cor- rected, for the violent peristalsis which accompanies diarrhoea is often productive of as bad, if not worse, results, than the straining efforts of constipation. Concealed Prolapse. In some cases of constipation, so-called, in infants, all efforts for successful treatment will fail ; and the author would advise in these cases the examination of the infant's rectum by means of a small- sized proctoscope or a large female cystoscope. Occasion- ally, this method of examination will be rewarded by the discovery of a prolapse of the third degree (Fig. Ill), which extends down to the rectum but does not protrude. In these cases the infant will be very fussy and will strain until red in the face, but all that rewards his efforts will be a small quantity of mucus stained with fecal mat- ter; and the only way in which the child's bowels can be emptied is by means of enemas. The same treatment as outlined for the incomplete prolapse is indicated in this condition. EDUCATION OF MOTHERS. 291 The principal point in the prevention and the treat- ment of prolapse of the rectum in children, is the edu- cation of the mothers along the line of the so-called train- ing of infants. While it is not the province of this work to go into the subject of infant feeding, nevertheless, the author feels that if more attention is paid to the pres- ence of sufficient hydrocarbon elements in the child's dietary, and the child is made to drink sufficient water, much good would result. Instead of forcing the little one to sit upon the toilet seat from half an hour to an hour and a half, or even longer, the child's bowels would move with regularity and with ease and prolapse would become a very rare condition. The squatting posture as assumed by the aborigines is the best for the children to assume. If after ten or fifteen minutes at the stool the child does not have a movement, it is better far to insert a soap suppository or administer a small enema to tide it over occasionally, than to indulge in the perni- cious custom, seemingly so prevalent. When in spite of strapping and the proper control of the bowel movements, the prolapse still persists in re- appearing, it becomes necessary to do something more radical. The method which has been most satisfactory in the hands of the author and which is particularly adap- table to prolapse of the rectum in children, is what is known as linear cauterization. This may be accomplished in two ways either by application of strong nitric acid or the use of the actual cautery. Neither method is ap- plicable with entire satisfaction unless a general anesthe- tic is employed. Nitrous oxide, however, can be used in these cases with perfect safety and makes a very depend- able and satisfactory anesthetic. 292 CAUTEB1ZATION BY NITRIC ACID. Cauterization by Nitric Acid. The child is placed in the lithotomy position with the prolapse unreduced, and is placed under the influence of the nitrous oxide gas. The protruding mucous membrane is wiped dry and a Fig. 112. Prolapsus of the Rectum, First Degree, Showing Radiating Lines of Cauterization. wooden applicator, one end of which has been wrapped with a very small quantity of absorbent cotton moistened with fuming nitric acid, is all that is necessary. The acid is applied in 4 to 6 radiating lines (Fig. 112), beginning at the uppermost portion of the center of the prolapsed muc- ous membrane at the lumen of the gut, and with consid- erable pressure a line is drawn or painted to, but not touching, the muco-cutaneous juncture. Four to six LINEAR CAUTERIZATION WITH THE ACTUAL CAUTERY. 293 equidistant cauterizations are made in this manner and an ointment composed of a drachm of bicarbonate of soda to an ounce of petrolatum freely applied. A piece of rubber drainage tube the size of a lead pencil, is wrap- per with gauze until it forms a plug or packing about % of an inch in diameter in its center and tapering at its extremities, is used to force the prolapse back into the rectum, and is left there for three or four days if pos- sible. The little patient's suffering after the operation is not very acute, but if there should be much pain, it should be controlled by suitable doses of codein or mor- phine hypodermatically; Vs to a /4 grains of codein will answer very nicely in children from l 1 /^ to 3 years old. The after treatment consists in the same methods and procedures as that advocated above in regard to diet, de- fecation in the recumbent position, the strapping of the buttocks, etc. After three weeks the child may be al- lowed to resume defecations in the squatting position. In the first dressing immediately after the operation it is wise to exert some pressure against the anus, by means of a suitable pad kept in place by adhesive plaster straps. Linear Cauterization with the Actual Cautery. The patient is prepared as described in the preceding para- graph and when the prolapse is protruding to its fullest extent, a Paquelin cautery armed with a blunt point, and heated to a white heat is used for making the cauteriza- tion in the same manner as the nitric acid is used. (Fig. 112.) One should be careful to carry the cauterization through the mucous membrane and into the muscular layer, but should be extremely cautious about burning through the muscular tissue. The amount of destruction 294 TREATMENT CAUTERIZATION. of tissue is more apparent than real; one must remember the object of the cauterization is to accomplish the con- traction of redundant tissues, and it is the contracting scar which invariably follows the use of the cautery, upon which we depend to accomplish the results. In this con- dition we take advantage of the great contraindication to the use of the actual cautery in the surgery of the rectum, for we well know that the scar produced by a burn >on mu- cous membrane, invariably contracts to such an extent as to lessen the calibre of the rectum. The after treatment dressing, packing, is the same as described where nitric acid is used as a cauterizing agent. Where these methods fail, there is nothing left to do but one of the cutting operations under surgical anes- thesia and preferable in hospital surroundings. When such is the case, the operation had best be done by one who is specially trained in this line of work, and not by the general practitioner; as the operative and after-care often taxes the patience, skill and ingenuity of even the trained specialist to accomplish the desired results. CHAPTER XV. THE TECHNIQUE OF THE USE OF LOCAL ANES- THESIA IN THE TREATMENT OF ANO- RECTAL DISEASES. If any excuse or apology were necessary for the pre- sentation of this work to the profession at this time, the subject matter contained in this chapter will be ample justification. The dangers, inconvenience, and necessary confinement to bed, and detention from business, which must attend the use of general anesthesia in many so- called minor operations, has created a demand and con- stantly enlarging field for the use in many departments of surgery, of local anesthetics. In the surgical treat- ment of diseases of the rectum and anus this is especial- ly true ; and while there are many diseased conditions of this region requiring surgical interference, the extent of which makes their operative treatment impossible with- out general anesthesia; there are, nevertheless, many of the more common diseases of this part of the body which are entirely amenable to surgical treatment under region- al anesthesia. The development of the use of local anesthesia in the treatment of anal and rectal diseases has progressed to such a stage, that it is safe to say, that fully 75% of 295 296 LOCAL, ANESTHESIA AGENTS USED. all cases of rectal and anal disease are amenable to treat- ment without the use of general anesthetics. Various anesthetic agents have been employed for the production of local anesthesia in this region, among which may be named the ethyl chloride spray, and the injection of solutions containing cocain hydrochloride, beta eu- cain hydrochlorate and lactate, alypin, stovain, novocain. chloretone, as well as plain sterilized water. Formerly, cocain in solutions varying in strength from 4 to 10 per cent were used. Symptoms of an alarming na- ture frequently developed after the injection of but a few drops of even a 4 per cent solution, which clearly demon- strated the toxic properties of the drug and the dangers of its indiscriminate use in strong solutions. Today we know that the extent of anesthesia produced depends, not so much on the strength of the solution, as upon the pressure anesthesia produced on the nerve endings, by the amount of solution injected, rather than its strength. Today, therefore, practitioners who are still partial to cocain are using solutions for injection, varying in strength from 1-10 of one per cent up to one-half of one per cent, and find the latter strength equal to the severest test. The author, after a trial of all of the anesthetics mentioned above, places his main reliance on beta eucain lactate where he requires a chemical anesthetic ; and plain sterile water in some few selected cases. The lactate of beta eucain is used in preference to the hydrochlorate because of the fact that solutions of the former salt can be sterilized by boiling without detriment. The strength of the solution varies according to the part to be anesthetized, as well as the amount of work ANESTHETIC SOLUTIONS. 297 to be done. For injection into the skin, and for the anes- thetization of the sphincterian nerves, one-fourth to one- half of one per cent solution is strong enough. For the distension of the tissues, for instance, in operating for fissure or internal hemorrhoids, a one-tenth of one per cent solution will suffice. Another important reason for my preference for eucain over cocain, is the fact that eu- cain is less than one-half as toxic as cocain, and is fully as powerful in its anesthetic properties. Chloretone, in the strength of one-half of one per cent, may be used with impunity in place of the one-tenth of one per cent solu- tion of eucain in such operations as require considerable amount of sol'ution. It is not toxic and has the added ad- vantage over the other drugs of being an antiseptic as well as an anesthetic. The use of sterile water as an anesthetic in the treatment of rectal and anal diseases, was exploited prominently a few years ago, and while the author's experience with it has proven to him that satis- factory anesthesia in certain cases can be produced by its use alone ; he limits its use in his work at present to the distension of internal hemorrhoids only. The one objec- tion which he has found to its indiscriminate use is the larger degree of discomfort to the patient at the initial Fig. 113. Aseptic All-Glass Hypodermic Syringe Provided With Asbestos Packed Plunger. 298 INSTRUMENTS REQUIRED. injection, and the large quantities of solution required in some operations in the sphincterian region, causing such distortion of the tissues, as to not only impede the work of the operator; but to displace the parts so that accurate work could not be done. It is well for the reader to realize that in "a pinch" sterile water can be used in lieu of any chemical anesthe- tic, and there are occasions when he may be called upon to do work in an emergency, where the various chemical anesthetics may not be available ; when, with an ordinary hypodermic syringe and boiled water satisfactory anes- thesia can be produced. Fig. 114. Aseptic All-Metal Syringe Provided With Extension for Infiltrating Through the Proctoscope. The principal instruments required for the production of local anesthesia is a hypodermic syringe such as is used for the injection of antitoxin; which may be con- structed either entirely of metal or glass (Figs. 113 and 114) so that it can be readily sterilized by boiling. This syringe should have a capacity of from 2 to 4 drachms. The needles used should be the finest that can be procured and the points should always be kept sharp. A quick punc- ture with a sharp pointed fine needle is almost painless, while the use of a larger calibred needle with a short bev- eled point, will cause considerable and unnecessary dis- comfort to the patient. The piston syringe package, con- PREPARATION OF PATIEXT. 299 structed of glass and rubber, which many of the manu- facturers of antitoxin supply, when sterilized by boiling, makes a fairly good substitute for the regular aseptic hy- podermic syringe, and in the absence of the proper ap- paratus it may be used. The objection to it is the fact that the needles supplied with it are usually of large cal- ibre and not as sharp as they should be for this work. The only other piece of apparatus required (and even that is not an absolute necessity) is a portable mechani- cal vibrator, armed with a cone-shaped rectal vibratode, (Fig. 117), for use in the dilatation of the sphincter muscle. The solution used should be accurately prepared as to the percentage of chemical anesthetic used. Where beta eucain lactate is employed, the solution is made up and placed in an ordinary test tube. It is sterilized by boiling over the flame of a Bunsen burner or spirit lamp, and then stoppered with absorbent cotton and allowed to cool. The solution is prepared freshly for each opera- tion. The patient is prepared for the operation as follows: Twenty-four hours before the operation, he is given a brisk cathartic and is instructed to partake of nothing but liquid food thereafter. On the morning of the opera- tion the bowels are washed out by means of a large soap enema, and he is directed to report at the office about one- half hour before the time for operation. He is then given a quarter of a grain of morphine by mouth. AVhen ready to operate, the patient is placed upon the table in the left lateral position, the left leg being ex- tended and the right well flexed. The clothing is placed well out of the way, and the patient covered with clean 20 300 TECHNIQUE FOB ANESTHETIZATION. sheets. The anus and perineum is shaved and scrubbed with liquid antiseptic soap, then washed with a one to 1000 solution of iodide of mercury, which is washed off Fig. 115. Exact Point of Puncture for the Injection of Local Anesthetics for Dilating the External Sphincter. With the patient in the lateral position, a point from % to ^2 inch posterior to the posterior commissure of the anus is chosen for the first injection. with sterile water, and a compress of alcohol applied. A point one-half inch below and posterior to the posterior commissure of the anus is selected. (Fig. 115.) A spray of ethyl chloride or the application of a drop of pure car- bolic acid is used to lessen the pain which accompanies the introduction of the needle. Wherever it is possible, the index finger of one hand, protected by a finger cot and well lubricated, is inserted in the anus; and the sphincter is pulled downward and backward. The syringe TECHNIQUE FOR ANESTHETIZATION. 301 containing about one drachm of one-half of one per cent solution of eucain lactate, with a fine sharp-pointed needle about two inches in length attached, is held in the other hand. The needle is inserted quickly, just underneath the Fig. 116. Showing the Amount of Distension of the Tissues Necessary in Anesthetizing the Sphincters. skin, and 4 to 5 drops of the solution slowly injected. One should be extremely careful about injecting the solution too quickly, as this part of the procedure is the most painful and often needlessly causes suffering, particu- larly to the timid and neurotic patient. The point of the needle is then passed inward and laterally, going down towards and into the external sphincter muscle which 302 TECHNIQUE FOR ANESTHETIZATION. guided by the finger in the rectum is brought down to- wards the needle. The point of the needle should be kept about one-half inch from the anal aperture and the injection is carried up along the posterior lateral quad- rant of the anus for about three-fourths to an inch. The needle is then retracted to the point of puncture but not withdrawn. It is then pushed up on the other side in the same manner, injecting the opposite side ; so that when the injection is completed the wheal of infiltration is U-shaped, the apex being at the point of puncture. (Fig. 116.) Fig. 117. Posture and Method cf Producing Dilatation of the Sphincter Ani by the Use of a Pcrtsble Vibrator Armed with a Cone- Shaped Vibratode. This technique allows of the anesthetization of the sphincterian nerves of both sides from but a single punc- ture. Care should be taken lest the rectal wall be punc- DILATATION OF SPHINCTER. 303 tured, but with the index finger of one hand in the aims during this procedure, such an accident should not oc- cur. Three or four minutes are allowed to elapse to al- low complete anesthesia to take effect ; then the vibrator, to which has been attached the cone-shaped vibratode, well lubricated, is pressed against the anus. (Fig. 117.) With very little pressure, but with the apex of the vibra- tode kept in the direction of the axis of the ano-rectal canal ; from two to three minutes vibration will dilate the sphincter painlessly to a sufficient calibre to allow what- Fig. 118. The Amount of Dilatation of the Sphincter Under Local Anesthesia. This drawing made from a photograph of one of the author's cases of internal hemorrhoids, well illustrates the amount of dilatation of the sphincter, which may be produced under locr.l anesthesia. While com- plete divulsion is neither possible nor necessary, sufficient distension is here secured to successfully remove the internal hemorrhoids seen in the drawing. 304 ANESTHETIZATION FOR EXTERNAL HEMORRHOIDS. ever operation is to be done, to be accomplished without difficulty. (Fig. 118.) Complete divulsion of the sphinc- ter can very rarely be accomplished by this means, but the dilatation will be amply sufficient for our purposes. The vibrator is a very convenient apparatus to have at hand, as the dilatation can be more quickly and evenly accomplished by its use. In its absence, however, one may use the index fingers of both hands protected by finger cots or rubber gloves, and by a gentle to and fro massaging movement, gradually accomplish dilatation in a very satisfactory manner. One should never use any of the dilating rectal speculums in the dilatation of the sphincter. The fingers are far better dilators, and can do no damage with intelligence and care behind them to guide them. The technique for operating for the various conditions amenable to operative treatment under local anesthesia will be dwelt upon more in detail in their respective chap- ters, while the differences in technique of anesthetization will be taken up below. Suffice it to say, however, at this point, that no operation upon the anus or rectum should be undertaken under local anesthesia, ivhich will require extensive dissection or over twenty minutes of time for its completion. External Hemorrhoids. If the hemorrhoid is entirely external and is not complicated by any other anal con- dition, it will not be necessary to anesthetize the sphinc- ter. After the usual preparation for operation, the most dependent hemorrhoid is injected from its base with one-half of one per cent solution of eucain lactate, about 20 to 30 minims being used directly under the skin. If ANESTHETIZATION FOB THROMBOTIC HEMORRHOIDS. 305 further distension is required in order to produce com- plete anesthesia, sterile water may be used for the deep- er injection. After two minutes the skin may be incised painlessly and the operation proceeded with. Where more than one hemorrhoid is to be operated, they may all be anesthetized at once, if the operator is rapid in his work ; otherwise they had best be anesthetized separately when ready to operate on each. Acute Thrombotic Hemmorhoids. The acute throm- botic hemorrhoid is usually single, occurring just at the anal margin. After being prepared for operation, eight or ten drops of the one-half per cent eucain solution is injected just beneath its outer covering, whether skin or mucous membrane ; care being taken not to inject deeply and into the clot. Sufficient solution should be used to distend the tissues over the clot and blanch them to white- ness. It may then be incised painlessly and the clot turned out. It is well after the turning out of the clot to inject the tissues beneath it, and examine carefully as sometimes a second clot may be found beneath the first, which must be removed in like manner. Perianal Abscess. In those cases of perianal abscess not extensive enough to require general anesthesia for their operative treatment, the use of a local anesthetic is well adapted. The technique of injection is the same as that outlined above for thrombotic hemorrhoids. The reader is cautioned to make his injection very carefully, so as not to perforate the abscess cavity with the needle. The solution must be injected into the skin itself and directly under it. After waiting two or three minutes for anesthesia to take place, the abscess may be opened with absolutely no pain. 306 ANESTHETIZATION FOR FISSURE AND FISTULA. Fissure in Ano. In all cases of fissure, the sphincter should be anesthetized and dilated. In many cases where the fissure is situated low down, the anesthetic solution injected for the anesthetization of the sphincter, will also be sufficient for the incision or excision of the fissure as well. Where the fissure is more extensive and with an in- durated base, or is located at some other portion of the anus than its usual site, the posterior commissure ; it must be injected separately. One-tenth of one per cent solu- tion of eucain or one-half per cent solution of chlore- tone may be used. The syringe should be filled. The needle should be inserted about one-quarter of an inch below the outermost extremity of the fissure, or beyond the sentinel pile when one is also present. The skin and mucous membrane surrounding the fis- sure or induration, as the case may be, should be infil- trated to such an extent, that the fissure is raised on a white waxy looking mound, and lies, as it were, on a water bed. It may require as much as three drachms of solu- tion, but distension of the tissues is essential before thorough work can be done. Anesthesia should be car- ried below the base of the fissure for at least a quarter of an inch. Fistula. The only variety of fistula in which it is ad- visable to use local anesthesia as a routine measure is that of a simple, shallow, complete, fistula whose course is direct and not branching'. A blind external or internal fistula whose opening is not over one inch from the anus and whose extent can be accurately gauged, may be opened under local anesthesia. As a gen- eral proposition, with the exception of the three ANESTHETIZATION FOR HYPERTBOPHIED PAPILLAE. 307 varieties mentioned, general anesthesia (nitrous oxide wherever possible) should be used in operations for fis- tula in ano. The sphincter should be anesthetized in all cases. The skin and mucous membrane above the fistula should be infiltrated with the 1-10 per cent eucain solution and then by successive injections the entire fistulous tract surrounding with the injected anesthetic fluid. The infiltration should be carried to the point of blanching. The operation then may be proceeded with as outlined in the chapter on fistula. Hypertrophied Anal Papillae. In cases where hy- pertrophy of the anal papillae is not accompanied by a tightly contracted sphincter, it is possible to remove the papilla under local anesthesia without dilatation of the sphincter. It is advisable, however, in order to overcome the tenesmus and painful spasmodic contrac- tions of the sphincter following any operation in the anal canal, to anesthetize the sphincter as a general rule in removing these papillae. "Where this is done the anus is held open by means of a retractor and each papilla is in- jected from base to apex with the 1-10 of one per cent eucain solution. It may then be removed painlessly, and each successive one injected in turn before removal. Where the sphincter is not anesthetized, the use of a short anoscope such as has been described by the author, with its internal opening on the slant, will be required. The papilla, as it hangs down or projects into the open- ing of the anoscope, is injected by means of a long needle attached to the hypodermic syringe, and injected as de- scribed above. Where it is desired to open the crypts of Morgagni as well, the needle should be carried up for 308 ANESTHETIZATION FOR VALVOTOMY. half an inch or so, when, after the removal of the pa- pilla, the crypt can be split open at will. Fig. 119. Author's Modification of the Martin Operating Proctoscope. The obturator has a conical shaped extremity and is made of metal. Hypertrophied Rectal Valves. In operating for the section of hypertrophied Houston's valves, the dilatation of the sphincter as outlined above, is often the only part of the operation, where a local anesthetic is required. The valves themselves are very poorly supplied with sen- sory nerves, and as a result, incision is painless. In some cases, however, there is some sensitiveness to pain ; so it is wise in all cases to be on the safe side, and apply by means of an applicator bent at a right angle, a four per cent solution of beta eucain to both upper and lower surfaces of the valve. After waiting two minutes, opera- tion may be begun. Removal of Foreign Bodies. Oftentimes small splint- ers of bone, pins or other swallowed foreign bodies will traverse the entire gastro-intestinal tract without doing any injury, or becoming lodged, until they reach the lower end of the rectum, when they impinge against the rectal aspect of the mucous membrane covering the sphincter muscle. By their constant irritation, they cause ANESTHETIZATION FOB PEBIANAL GROWTHS. 309 spasm of the muscle and intense suffering. On account of the tonic contraction of the sphincter, which is caused by this irritation, any attempt at the insertion of a proc- toscope or even the finger is usually futile. The dilata- tion of the sphincter by means of the technique outlined above, is nowhere more applicable than in this class of cases, and not only such foreign bodies as have been mentioned, but fecal concretions and impactions of con- siderable size can be removed without the employment of a general anesthetic as well. Removal of Benign Perianal Growths. Small benign growths situated at or near the anal orifice, such as der- moids, sebaceous cysts, lipomata or condylomata are very satisfactorily removed under local anesthesia, under the following technique: After the parts are cleansed, sterilized and shaved, condylomata are removed by the application of a 4 per cent solution of eucain to the parts, which is repeated every two or three minutes for 10 minutes. Then if anes- thesia is not complete, the parts are sprayed with ethyl chloride solution, the condylomata quickly snipped off with sharp scissors curved on the flat, and fuming nitric acid applied with a wooden applicator, or a small tight swab. Boro-chloretone powder is then applied, and the parts covered with a gauze dressing. In the case of a dermoid or sebaceous cyst, or fatty tumor, the technique is the same for the removal of any of the three varieties. The skin covering the tumor is first injected with one-half per cent solution of eucain lactate, a wheal or welt being formed over the proposed line of incision. The incision is made and the tissues above and surrounding 310 ANESTHETIZATION FOR POSTERIOR PROCTOTOMY. the tumor infiltrated with one-tenth of one per cent solu- tion of eucain lactate or sterile water; when the dissec- tion and removal of the growth can be accomplished easily, with forceps and scissors. Care should be taken in the cases of a cystic tumor not to puncture the cyst wall with the injecting needle, and in the excision of the growth to be sure to remove all of the sac. If this is not done, recurrence is liable to follow. Posterior Internal Proctotomy for annular stricture situated in the anal canal, or not over one-half an inch above the ano-rectal juncture. With the patient in the left lateral position, and pre- pared for operation, the region posterior to the anus, anal canal, and stricture, is infiltrated with one-tenth of one per cent solution of eucain lactate. After waiting two or three minutes for anesthesia to take full effect, the stricture is divided in the posterior median line down to the rectal wall, with a sharp scalpel, a piece of gauze inserted, and the operation is complete. The au- thor's technique for rectal valvotomy by the use of the rubber ligature may be substituted for the incision, if the calibre of the stricture is sufficiently large enough to admit the ligature carrier. After operation, the recur- rence of the stricture is prevented by the introduction of Wales' bougies up to size No. 12, twice a week at first, and at increasing intervals until complete healing has taken place. After carefully perusing what has been said regarding the employment of local anesthesia, and bearing in mind the contra-indications and objections as outlined in the following chapter on Limitations of Local Anesthesia; OTHER INDICATIONS. 311 other diseased conditions of not only the rectum and anus, but in other parts of the body, will present them- selves, in which the employment of local anesthesia will be found very advantageous; and the results obtained therefrom fully as successful as where heretofore, the employment of general anesthesia has been thought abso- lutely necessary and indispensable. CHAPTER XVI. THE LIMITATIONS OF OFFICE TREATMENT AND INDICATIONS FOR OTHER MEASURES. While the primary object of this work has been to bring before the profession, the advantages to be gained from the treatment of various rectal diseases in office practice, and to demonstrate the advantages of the use of local anesthesia in the treatment of many of the more common conditions met with in connection with the treat- ment of diseases of the anus and rectum; it has been thought wise to utter a warning note, lest the reader be led away by over-enthusiasm. While the author believes that the field for the employ- ment of local anesthesia in rectal surgery, as well as in other branches of practice, is rapidly widening ; he wishes to impress upon the reader that this field has definite limitations and that there is, and always will be, a large class of cases whose successful treatment requires more radical measures, ivhich only can be employed by the aid of full surgical general anesthesia. If the reader has carefully read what has been said upon means and methods of diagnosis, and has noted in the various chapters following, the class of cases in which the author advocates the use of non-surgical meas- 312 LIMITATIONS OF OFFICE TREATMENT. 313 ure and the employment of local anesthesia ; he will have noted that the methods of treatment advocated are con- fined to a very definite class of cases. All of the condi- tions treated of, have been located either at, or in the immediate vicinity of the anal canal, or were those affec- tions of the mucous membrane of the rectum or lower sigmoid, which are accessible to treatment through the proctoscope or sigmoidoscope. The first thing one should remember before commenc- ing the treatment of any pathological condition found in the region of the anus, is that until a careful exploration of the entire rectal cavity has been made, and every portion of it examined with the eye; he has not made a diagnosis, and has no right to treat the patient until he has. It would be a sad and unfortunate discovery for the physician who has been treating an anal ulcer, or pru- ritus, or hemorrhoids, to discover after several weeks, that the condition under treatment was merely second- ary to an extensive ulceration higher up in the rectum, a stricture, or malignant disease. In women, suffering from pelvic troubles which may require laparotomy for their relief, the removal of any minor rectal condition present under local anesthesia, had better be postponed, and the rectal or anal condition treated at the time of laparotomy. In patients suffering from irregularity or interrup- tion of their normal bowel movements, it is wise to ex- clude by careful abdominal examination any possibility of chronic intestinal obstruction, due to some abdominal growth, displacement, or adhesions; than to attempt to relieve the patient by means of rectal dilatation and mas- sage. 314 CONTRA-INDICATIONS TO THE USE OF LOCAL ANESTHESIA. Every patient presenting himself with a fissure or ul- cerative condition of the anal canal, should be carefully questioned as to the possible history of previous syphilitic infection. The presence of gonorrhoea! discharge, is a centra-indication to operative measures until the disease is remedied. In women, a purulent vaginal discharge as well as the menstrual flow is of course, a contra-indica- tion. Patients suffering from anemia are always bad sub- jects for operation at one's office under local anesthesia, and a history of hemophilia should always be excluded before office operations. Patients of a highly neurotic temperament and hysterical females are best operated at home or in the hospital, and under general anesthesia. In other words, the suitable cases for office treatment are those suffering from diseased conditions, ivhose patho- logical source is located either on the mucous surface of the rectum and lower sigmoid, and is definitely circum- scribed in area and not of a malignant, syphilitic or tu- bercular type; or to lesions occurring at or around the anal orifice, ivhose outlines can be definitely marked out by the diagnostic means outlined in the fore part of the book. One of the greatest satisfactions to the practitioner who as a routine measure makes a proper rectal exami- nation of his patients whose symptoms would seem to indicate it, is the discovery of commencing malignant disease early enough to allow of the removal of the pri- mary focus, and the saving of his patient's life. As has been said before, a history of rectal hemorrhage, how- ever slight, is an imperative demand for complete explo- RECTAL CANCER. 315 ration of the rectal cavity and the most important con- dition to be on the lookout for, which makes itself mani- fest early by rectal hemorrhage is cancer. It is in this Fig. 120. Cancer of the Rectum, With Multiple Fistulae. This drawing, made from a photograph of a case referred to the author, tells a pathetic story. The patient, a woman aged 52. suffering from various digestive disturbances and the appearance of blood with the stool, made her own diagnosis of ''bleeding piles;" after six months of self-treatment she consulted an irregular advertising quack, who confirmed her diagnosis of "hemorrhoids," and proceeded to "absorb the growth by electricity." When her money ran out she was sent home "cured." Her condition one month later, when seen by the author, is illustrated above. The area of infiltration involved the entire anus, posterior wall of the vagina, and all of the perineal body between. Her perineum was riddled with abscesses and fistulae. The rectum and vagina communicated through a large recto-vaginal fistula, and the posterior wall of the bladder was infiltrated. The case was hopeless and she died shortly afterwards. 21 316 SYMPTOMS OF RECTAL CANCEE. condition, above all others, where an early complete proc- tologic and sigmoidoscopic examination will achieve bril- liant results, if the findings therefrom, will bring about an early operation for the removal of the growth. It is the same with malignant diseases in this part of the body as in all others ; if the surgeon can only get at them early enough to thoroughly eradicate, he can relieve them with a pretty definite hope of permanent cure. Inasmuch as rectal cancer most frequently occurs in the lower part of the organ, the early operation and com- plete removal is productive of much good. Some of the early symptoms of commencing cancer of the rectum or sigmoid are flatulence ivith colicky pains; diarrhoea al- ternating with constipation; tenesmus; increased mucous discharge, ivhich is usually offensive in odor, and hemor- rhage. This hemorrhage is very slight at first, often showing a few blood streaks with the mucous, or small passages of blood either with the stool or occasionally between bowel movements. The nearer to the anus the cancer is located, the earlier in the disease the hemor- rhage, on account of the traumatism to the groivth caused by the passage of the feces. Cachexia, loss of weight and impairment of general health is not an early sign of rectal cancer. The indican reaction is usually present in urine in cancer, while it is absent in ordinary diar- rhoea. Diarrhoea which persists for some time, which is ac- companied by the presence of blood, however slight, should be regarded as suspicious and the patient care- fully watched. When one considers that 50 per cent of all cancer occurs in the gastro-intestinal tract, and that RECTAL CANCER. 317 16 per cent of all cancers of the digestive tract occur primarily either in the rectum or sigmoid flexure; one commences to realize the importance of examining every Fig. 121. Proctoscopic View of Carcinoma Situated Just Below the Juncture of Rectum and Sigmoid. (Drawn through the proctoscope. Author's case.) ! case which presents a history of rectal hemorrhage, how- ever slight, no matter the age or general appearance of the patient. Well authenticated cases of cancer of the rectum have been found in cases as young as fifteen years of age. To show how much more frequently cancer is prone to locate in this part of the body than is generally supposed, it may be stated that Boas found in 500 cases of cancer of the di- gestive tract, 83 cases of cancer of the rectum. In the per- sonal practice of the author, very frequently patients are brought in by practitioners, many of whom really try to do conscientious work, with unsuspected cancer of the 318 RECTAL CANCER. rectum. Many of these patients are in the forties, pres- ent robust appearance and come with a history of some bleeding from the rectum from which they make their Fig. 122. The Carcinoma Shown in the Preceding Illustration. Drawn from the specimen removed by operation. own diagnosis of "bleeding piles." They also complain of some disturbance of bowel movements, either constipa- tion or diarrhoea, and disturbed gastric and intestinal digestion and occasionally a not very well defined aching in the sacral region. In many of these cases proctoscopic and sigmoido- scopic examination has demonstrated the presence of cancer of the rectum, so far advanced, as to cause almost complete occlusion of the lumen of the bowel, and too RECTAL CANCER. 319 far advanced to extirpate with any hope of cure. It is the unfortunate experience of many proctologists to be Fig. 123. Cancer of the Rectum. Photograph of specimen removed by the author. This specimen, which includes the entire rectum and lower portion of the sigmoid, being eleven inches in length, was removed by the author by the perineal method, the sphincters being preserved. This case well illustrates the value of early diagnosis and prompt operative interference in cancer of the rectum. The patient, aged 50, suffered from gradually increasing disturbances of the digestive functions for about six months. The symptoms gradually grew worse and she noticed that her stools were becoming smaller in calibre and accompanied by a small quantity of blood. She consulted her physician, thinking she had hemorrhoids. He immediately made a proctoscopic examination and discovered just below and extending to the recto-sigmoidal juncture, a crater-like ulcer- ation with raised edges, projecting into the lumen of the bowel. A diag- nosis of rectal cancer was made and the case referred to the author for operation. There was no extra-rectal involvement and the complete extirpation of the diseased rectum and lower sigmoid was followed by a rapid recovery of the patient. 320 RECTAL CANCER. called upon to inform many of these patients of their hopelessness, and it is with the hope of bringing the pro- fession in general to realize the importance of examina- tion of the rectal cavity in all cases presenting the symp- toms just mentioned above ; that so much stress is being laid on the importance of early examination of the rec- tum by the general practitioner. Fig. 124. Cancer of the Rectum. Same as the preceding. Interior view of the specimen. A. Point of amputation from the anus. R- Rectum. X. Cancer. S. Sigmoid flexure. The lettering on the preceding specimen corresponds to the above. ULCERATION COLOSTOMY STRICTURE. 321 Cases of ulceration of the bowel involving more than one circumscribed area which have become chronic, as well as the very extensive ulcerations due to the specific infections like tuberculosis and syphilis, are not suitable cases for office or local treatment. It has been found in the experience of most proctologists that the only satisfac- tory way by which such cases may be cured, is by " side- tracking" the fecal current by means of a temporary colostomy. This removes the mechanical as well as the bacterial irritation from the ulcerated surfaces and puts the parts at rest ; after which irrigations and other suit- able therapeutic measures can be applied from above, as well as below. These cases, however, require more or less confinement to bed or to the house, and are best treated only in the surroundings which the modern hos- pital can best supply. While it is true that colostomy can be performed un- der local anesthesia, as the author has demonstrated in several cases; it is hardly to be advised to be performed by the general practitioner or included in the same class as the operative measures or diseases mentioned in the foregoing chapters. No case, of stricture of the rectum should be treated whether by dilatation, incision, or electricity in office prac- tice, unless it is situated within the first two inches of the ano-rectal canal, and is not smaller in calibre than the circumference of a No. 10 Wales bougie. Even then, its situation, consistency, structure and relation to the rectal walls and impinging organs, should be definitely ascertained by digital and instrumental, as well as ocu- lar examination. Great caution should be observed in 322 CIRCUM-AXAL AND PERI-RECTAL ABSCESSES. using forcible dilatation in any case of stricture of the rectum, no matter how elastic the stricture may seem. Accidents have been reported where the rectum has been torn through, and the peritoneal cavity entered with fa tal result, from the simple dilatation of large calibred strictures by means of the Wales bougie. Cases of ' ' stric- ture" due to unusual infiltration of one of Houston's valves, or strictures of the umbrella type can be easily divided by means of the author's rubber ligature opera- tion, as applied to hypertrophied rectal valves. Where the administration of nitrous oxide is so easy, and attended with practically no danger, its use is to be advocated in those cases where operation of a few min- utes' (not exceeding twenty-five) duration is all that is required, for which general anesthesia is absolutely necessary. While, as has been pointed out in a preceding chapter, some circum-anal and peri-rectal abscesses are amenable to treatment, within certain limitations, under local anes- thesia; abscess formation may go on to such a point, that it is absolutely necessary to do a more extensive operation than is possible under local anesthesia. Cer- tainly no abscess which extends above the levator ani muscle should ever be opened under local anesthesia; nor any abscess in the ischio-rectal region, in which there is any doubt as to the operator's ability to obtain a large and free drainage opening by means of incision without curetting. Owing to the ease with which an abscess may extend, and the rapidity with which it enlarges in the ischio-rectal region, it is a safe plan not to attempt to open the abscess under local anesthesia, if it has become FISTULA IN ANO HEMORRHOIDS. 323 larger than a hen's egg in size, unless a definite point of fluctuation and softening can be detected at a point, well outside of the sphincters. No case -of fistula-in-ano which has more than one channel or whose limits cannot be definitely made out by digital examination, should be opened under local anes- thesia. Only the simple, direct, complete, or blind exter- nal, blind internal, or sub-mucous fistulae, are amenable to operation under local anesthesia and in cases of doubt, nitrous oxide or ether should be employed. One never can tell how high, or how extensive a dissection may be required for the complete removal of a fistulous tract, which is the ideal operation. In operating for hemorrhoids under local anesthesia, one must be extremely careful in the selection of cases- Hemorrhoids complicated with fistula, extensive ulcera- tion, prolapse, or abscess, are best treated only under general anesthesia. External hemorrhoids and acute thrombotic hemorrhoids can almost invariably be re- moved under local anesthesia, fully as satisfactorily as by the use of a general anesthetic. In the treatment of internal hemorrhoids and externo-internal hemorrhoids, however, there is a limit beyond which it is possible to go, but not wise. The author in his practice has laid down the following rule: In all cases of internal hemorrhoids where not more than four separate hemorrhoidal tumors are present, whether prolapsing or not (see Fig. 85), operation under local anesthesia is the method of choice. Where more than four distinct hemorrhoidal tumors are present, or where there is much rectal prolapse complicating, their removal 324 PROLAPSE OF THE RECTUM. under nitrous oxide anesthesia is advised. Where, how- ever, it is deemed unsafe or inexpedient, or where the pa- tient absolutely refuses to take a general anesthetic; the more severe cases can be operated on under local anes- thesia by operating at several different sittings, remov- ing two or three hemorrhoids at a time, and then in a month or so removing more; eventually accomplishing the complete removal of all the hemorrhoids in three or four months and by as many operations. In some pa- tients suffering from cardiac, pulmonary or renal disease, such a method may have to be followed where the admin- istration of a general anesthetic would be absolutely pro- hibited. In cases suffering from interno- external hemorrhoids. where there are more than four separate tumors, their removal may be accomplished in two sittings by remov- ing the external portions at one operation; when, with these out of the way, the internal ones can be removed with ease at the next sitting. In prolapse of the rectum of the second degree, where the prolapsus only involves one-half of the circumfer- ence of the bowel, local anesthesia may be employed and the prolapsed portion ligated off in sections. As a gen- eral proposition, however, the author does not advise its use. Operations for prolapse have been done by some proctologists under local anesthesia, but the technique is rather crude, and the same satisfactory results cannot be obtained in this hurried method, as are possible under general anesthesia. In prolapse of the third degree (Fig. Ill), local anesthesia is obviously contra-indicated, as the most successful operations for the reduction of complete FECAL, CONCRETIONS COMMUNICATING FISTULA. 325 prolapse is best accomplished by means of an abdominal operation. The removal of concretions from the rectum or sigmoid which are larger than one inch and a half in circumfer- ence, should not be attempted under local anesthesia, but can be done very nicely under the anesthesia produced by the administration of nitrous oxide. While almost any case of fecal impaction can be relieved under local anes- thesia, as has been pointed out in Chapter V, there are some cases in which the procedure fatigues the patient so much, that the administration of a general anesthetic may by necessary, in order to successfully complete the opera- tion. Operations for fistula communicating betiveen the rec- tum and other adjacent organs should never be attempt- ed under local anesthesia; neither should the extensive use of the thermo cautery be attempted unless the patient is under profound anesthesia, if used at all. Before at- tempting any operation for relief of any pathological condition discovered in the anus or rectum, the absence of any other diseased condition higher up in the rectum, should first be demonstrated by careful proctologic and sigmoidoscopic examination. CHAPTER XVII. THE FECES AND THEIR CLINICAL EXAMINA- TION. BY GEORGE W. WAGNER, M. D., Detroit, Mich. It is surprising that in the study of intestinal diseases so little attention has been given to the careful study of the stool. The study of the feces bears the same re- lation to the study of intestinal derangements, as the examination of the urine to the diagnosis of renal dis- eases. I have, as far as possible, included only the practical part of cropology, omitting those procedures that are of no particular benefit to clinical medicine and those re- quiring special laboratory training. Under the term feces are comprised all those sub- stances which, being formed from the food in the process of digestion, and mixed with the residues of the secre- tions of the alimentary canal, are finally expelled by the rectum. Number of Stools. The number of stools in 24 hours varies greatly in different persons, who are apparently in good health. One may have two to three bowel move- ments in 24 hours, while another may have but one in 48 hours, so it is important to ascertain the habitual num- 326 DURATION OF PASSAGE. 327 ber of stools in every individual. There are rare in- stances in which one stool occurs only in 2 to 6 weeks. It is better, however, to take the general condition of the patient as a guide to the sufficiency of defecation. Some individuals will tolerate infrequent defecations while others would suffer from copremia under the same con- ditions. Duration of Passage. The question of the length of time required for the passage of food through the gastro-intestinal canal is a matter of much clinical im- portance, yet little attention has been paid to the subject. It is quite as important to know the period of passage as to know how often the patient has a stool. A patient may have one stool a day, and yet have latent constipa- tion, which gives rise to toxic symptoms. Whether latent constipation is present can only be determined by esti- mating the period of passage. In diarrhoea, by estimat- ing the period of passage, it is possible to come upon an approximate idea of the seat of the disturbance produc- ing the diarrhoea. If the period of passage is nearly normal, the trouble lies in the lower or middle portion of the large intestine, and peristalsis is probably not in- creased in the small intestine. Chronic colitis, with sev- eral watery movements a day, may be accompanied by a normal passage. The period is decidedly shortened if the inflammation is in the ascending colon or small bowel. Strauss used a test diet of 100 gms. of lean meat and found the normal period to be 10 to 20 hours. This was increased in cases of constipation as high as 60 hours. Maurel using a pure milk diet, gives the normal period 36 to 48 hours. In disease the shortest period was 4 hours, 328 NORMAL CHARACTERISTICS. and in such cases the bilirubin is found unaltered. The period of passage is very easily marked by giving a cap- sule of carmine with the meal and watching for the first red stool. Amount. The amount varies in different individ- uals, depending upon the character of the diet and the condition of the digestive organs. The quantity is in- creased by a diet rich in vegetables and starchy foods, and diminished by one rich in animal food. The stool consists of the indigestible portion of the diet, the part of the diet undigested, bacteria and the secretion of the intestines and their associate glands. Cetti, who fasted 10 days, passed about 22 gms. of stool on the average per day. The normal amount varies be- tween 100 and 200 gms. in 24 hours. Consistency and Form. The consistency of the stool depends chiefly upon the amount of water it contains, though there may be soft, thin stools due to abnormal amounts of fat or mucus. Increase of the fluid in the stools may be due to deficient absorption or to exudate or transudate from the mucous membrane. Increased peri- stalsis may cause watery stools through failure of absorp- tion, while prolonged retention in the colon or rectum may result in hard, scybalous masses due to excessive absorption of water. Odor. The odor of the feces is, to a large extent, due to the presence of indol, skatol, sulphuretted hydrogen and methane. Color of Stools. The color of the feces varies ac- cording to the nature of the food ingested. The normal color is a dark brown. A diet consisting largely of meat MACEOSCOPIC ELEMENTS. 329 gives an intensely brown stool, while a vegetable diet gives a more yellowish shade to the feces. A stool that has been exposed to the air is darker on the outside than Fig. 125. Sulphide of Bismuth Crystals From the Stools. (Eye piece III, objective 8 A, Reichert.) Clinical Diagnosis : von Jaksch & Cagney. on the interior, owing to the process of oxidation. The presence of undigested fats gives a yellowish shade to the stool. If much blood is present the stool may be black or have a tarry appearance. Huckleberries and red wine produce a dark stool; chocolate and cocoa, gray; iron manganese and bismuth preparations a dark or black stool owing to the formation of the oxides of these met- als. (Fig. 125.) Calomel causes a greenish stool (bili- verdin), santonine, rhubarb and senna produce a yellow color. Macroscopic Elements. These are derived either from the food or from the intestinal apparatus itself. It is possible to find stones, cherry pits, 330 MICROSCOPIC ELEMENTS. grape seeds, skins of various berries or apples, pears etc., pieces of connective tissue, grains of corn- in fact almost any part of the food if insufficiently masticated. The presence of casein in the stools of in- fants appears as small whitish lumps and can, as a rule, be easily recognized. Foreign bodies of almost every description that are not too large to swallow, may be found in the stools, especially in the stools of children and of the hysterical or of the insane ; one may find buttons, coins, pins, false teeth, hair balls, etc. Fig. 126. Collective View of the Feces. (Eye piece III, objective 8 A, Reichert). a, Muscle fibres; b, connective tissue; c, Epithelium; d, White blood corpuscles; e, Spiral cells; f-i, Various vegetable cells; k, Triple phosphate crystals in a mass of various micro-organisms; I, Diatoms. Clinical Diagnosis : von Jaksch & Cagney. Microscopically, may be seen indigestible and undi- gested portions of the food as well as substances thrown off by the mucous membrane of the intestines. Thus, starch granules and remnants of chlorophyll, muscle fibre, elastic tissue fibres, connective tissue fibres, flakes of casein, white blood corpuscles, triple phosphate crys- tals, micro-organisms, etc., may be seen. (Fig. 126.) CLINICAL EXAMINATION. 331 The Clinical Examination of the Stools. In order to make the clinical examination of the stools of benefit and satisfactory, we must have a standard for compari- son. Schmidt, of Dresden, has formulated a diet to meet this requirement and it, or some modification, is now in general use by those following this line of work. There are two conditions for the satisfactory clinical examina- tion of the feces. 1. A knowledge of what a normal stool should be un- der a certain diet. 2. The methods of examination must be as simple as possible. 1. The test diet The requirements are: (a) That it must be nutritious enough to furnish calo- ries sufficient for the body's need. (b) It must consist of such articles of food as can be obtained in any household. (c) It must contain a constant amount of certain ar- ticles, so that variation in digestion and absorption can be detected in the stool. Schmidt's diet is as follows: 1.5 litres of milk, 100 gms. Zweiback, 2 eggs, 50 gms. butter, 125 gms. very rare or raw beef, 190 gms. potato, and gruel from 60 gms. oatmeal and 20 gms. sugar. This may be divided as follows : Breakfast Two eggs, half liter or two glasses of milk, one-third the amount of Zweiback and butter, or two slices of well toasted bread, with butter, and the oat meal and sugar. Dinner The steak and potatoes one-third Zweiback and butter and two glasses of milk. 332 CLINICAL EXAMINATION. Supper Two glasses of milk and the remainder of toast or Zweiback and butter. The amounts of each article should be measured or weighed accurately and the beginning of the test diet marked by giving a capsule containing carmine or char- coal, preferably the latter because carmine would inter- fere with the color reaction in case an examination is made for blood in the stool. This diet should be given for several days. The first black stool will denote the length of time required for the passage of food through the gas- tro-intestinal tract. The examination of the stool con- sists of the following steps: The consistency, color, and smell must be observed. Then a piece of formed stool the size of a walnut or an equivalent amount of liquid feces is rubbed up in a mortar with distilled water until it is quite smooth and liquid. Part of this is poured upon a glass plate or a Petri dish, put over a dark back- ground and examined in a good light. In normal digestion, very little should be seen by the raked eye except small brown points (oatmeal), and occa- sionally sago-like grains that look like mucus, but which the microscope shows to be grains of potato. Pathologically, there may be: 1. Mucus in large or small flakes which is not affected by rubbing up in the mortar. The smaller the flakes the harder they are to recognize. It appears as glassy translucent flakes, often stained yellow by bile pigment. If at all doubtful, the microscopic examination will clear it up. 2. Pus, blood if considerable, can be easily detected, as can also parasites, stones and foreign bodies. CLINICAL, EXAMINATION. 333 3. Remnants of muscle fibre appear as small, red- dish brown threads or small irregular lumps. When they can be easily seen by the naked eye and are quite numer- ous, it shows impairment of intestinal digestion. 4. Remnants of connective tissue and sinew from the beefsteak can be detected from the mucus by their tough- ness and whitish-yellow color. If in doubt, a piece may be put on a slide with a drop of acetic acid and examined with the microscope. The connective tissue loses its fibrous structure while the mucus becomes more thread- like. Small pieces of connective tissue can be found in normal stools, but when they are numerous and large their presence indicates the impairment of gastric di- gestion. 5. Remnants of potato look like grains of boiled tapi- oca and may be confused with mucus. Any doubt of the nature of the particles can be cleared up by the micro- scope. 6. Large crystals of acid phosphate of ammonium and magnesium occur in foul stools, and can be easily recog- nized by their shape and chemical reaction. (Solubility in all acids.) For microscopic examination, prepare three slides from the liquid feces. The first a drop of the material to be examined un- der high and low power. The second slide mix a drop of the material with a drop of acetic acid (U. S. P), heating it to the boiling point, then put on the cover glass. The third slide a drop of the material with a drop of weak Lugol solution (Iodine 1, K. I. 2, Water 50). 334 CLINICAL EXAMINATION. Fig. 127. Muscle Remnants in Feces. (Leitz objective VII.) a, large ; b, medium ; and c, small fragments. From Schmidt & Strasburger. Normal Stool. Slide one: (a) Single small muscle fibres, colored yellow, usu- ally with a cross striation. (Fig. 127.) (b) Small and large yellow crystals of salts of fatty acids. (c) Colorless particles of soap (gray). (d) Single potato cells. (e) Particles of oatmeal. Fig. 128. Haematoidin Crystals from Acholic Stools. (Eye piece III, objective 8 A, Reichert.) von Jaksch & Cagney. CLINICAL EXAMINATION. 335 In the second slide a general idea of the fat content of the stool can be obtained. Upon cooling, small flakes of fat acids can be seen. The large crystals of salts of fatty acids and the soap are broken up by the acetic acid, and fat acids are liberated. If the slide is heated again and examined while hot, the fat acids will be seen to run together in drops, which, as the slide cools, break sud- denly apart. In the third slide, there should be violet-blue grains in some of the potato cells, and small single blue points, probably fungi spores. Fig. 129. Acholic Stools. (Eye piece III, objective 1-15, oil immersion, Reichert, Abbe's mirror, narrow diaphragm.) von Jaksch & Cagney. Pathologically There May Be. Slide 1: (a) Muscle fibre in excess, perhaps with yellow nu- clei. (b) Neutral fat drops or fatty acids in crystals. (c) An excess of potato cells with more or less well preserved contents. (d) Parasite eggs, mucus, connective tissue, pus, etc. Slide 2. Fat acid flakes in excess. Slide 3. Blue starch grains in potato cells or free oatmeal cells, fungus spores or mycelia. 336 CHEMICAL EXAMINATION. Chemical Examination. The Reaction. The reaction of the stool is hard to get with litmus paper, but can be easily obtained by dropping a little softened fecal matter into five or ten c.c. of a weak, watery solution of litmus, shaking it and noticing the change. It is well to use another test tube with the litmus solution only, as a control. The test should always be made with freshly passed feces, inas- much as the reaction of the feces may change upon standing. The Sublimate Test. Consists of taking of a few c.c of the liquid feces and mixing it with an equal amount of 25 per cent watery solution of mercuric chloride. A nor- mal stool will turn a pinkish-red, indicating the presence of hydro-bilirubin, which will be more intense the fresher the material. A green color, even if it is detected micro- scopically, is pathologic and indicates unchanged bile pigment. Fermentation Test. About 5 gms. of fresh formed feces is taken, or an equivalent amount of thinner ma- terial. Steele's Fermentation Apparatus, modification of Strasburger's is used. It is constructed of perforated rubber corks, bent glass tubing, and two test tubes of 30 c.c. capacity. (Fig. 130.) A small glass tube beam runs up to the top of the test tube C to allow for the escape of air. The stool is rubbed up with sterile water and poured into the main bottle A. This is filled with sterile water; tube B is filled with water and fitted in place, and tube C is then fitted on empty. The reaction is carefully noted before the test is started. The apparatus is then stood CHEMICAL EXAMINATION. 337 in a warm place for 24 hours, best in an incubator at 37 degrees, (centigrade). If gas forms by fermentation in A, it will rise into B and the amount will be indicated by the water displaced into C. Normally, the fermentation test should show practically no gas, and the original reac- Fig. 130. Steele's Modification of Strasburger's Fermentation Apparatus. It is constructed of perforated rubber corks, bent glass tubing, and two test tubes, each of 30 cc. capacity. The small glass tube D runs up to the top of the test tube C to allow for the escape of air, instead of the test tube being perforated, as in Strasburger's apparatus. Progressive Medicine, December, 1905. 338 CHEMICAL EXAMINATION. tion should be unchanged for 24 hours. If more than one-third of the tube C is filled, it is pathologic. If, then, the reaction is decidedly more acid, it is a carbohydrate fermentation; if alkaline and with a foul smell, it is a fermentation of albumins. Estimation of Lost Albumin or Albumin Residue. A qualitative test may be made as follows : A softened portion of the stool is filtered, the filtrate shaken with silicon and re-filtered, then it is saturated with acetic acid to bring down the nucleo-proteids, after filtration a drop of ferrocyanide solution is added. A decided precipitate indicates albumin. It was formerly thought that a positive test showed a diminution of albumin digestion, but the work of recent investigators would indicate that this is not the case. Under pathologic conditions, the nucleo-proteids may be decidedly increased, although their presence is not char- acteristic of any particular disease. Other forms of al- bumin are rarely found in the feces, even after the inges- tion of excessive amounts. The occurrence of albumin in the feces of adults is almost always associated with diarrhoea and usually with an excessive formation of mucus. It usually is serum albumin much less frequently albumoses. Such "lost albumin" in the stools indicate severe anatomical changes in the bowel but usually not disturbance of absorption. The albumin under these cir- cumstances conies from the intestinal wall, and sometimes a part of them may be digested by the intestinal ferments into albumoses. CLINICAL, SIGNIFICANCE OF TEST. 339 Clinical Significance of Test. Mucus. There are two conditions in which the presence of mucus in the stools has no significance : When hard, dry masses of feces are covered with thin mucus, without evidence of rectal inflammation, and when it is discharged in casts, the so-called mucus colic. Otherwise it indicates inflammation of the intestinal mucous mem- 'Wf*sv J'i^iii^W'- Fig. 131. Mucus Shreds. From Schmidt & Strasburger. brane. If it is densely impregnated with bacteria, food remnants, and detritus the origin of the inflammation is probably high up in the intestine. (Figs. 131-132.) Bilirubin discoloration affords no certain evidence of inflammation of the small intestine, but the presence of bilirubin granules and crystals in a cellular arrange- ment is suggestive. The presence of semi-digested cells or of their nuclei indicates an origin high up in the bowel. The presence of hyaline cells favors the assumption that an inflammation of the colon exists. Bile Pigment. A green color of part or all of a stool, by the sublimate test, is pathologic, except in chil- 340 CLINICAL SIGNIFICANCE OF TEST. dren. It means a too short period of passage through the intestine, and that time for a normal reduction process of the bilirubin into hydro-bilirubin was lacking. A nor- Fig. 132. Mucus Shreds After the Addition of Acetic Acid. Urine and Feces in Diagnosis: Hensel, Weil, and Jelliffe. mal fresh stool will give a pink color with mercuric chlo- ride. If a color reaction of any kind is absent, it indi- cates a very fat stool, or an absence of bile in the intes- time. (Fig. 129.) The assumption of the temporary stoppage of the bile does not account for all of the cases of colorless feces which do not darken on exposure. The pathologic con- ditions in which colorless feces without jaundice may oc- cur comprise defective supply of bile to the duodenum, intestinal catarrh, tuberculous abdominal disease, malig- nant disease of the intestine, septic diseases (especially those which affect the abdomen), chlorosis and leukemia. CLINICAL SIGNIFICANCE OF TEST. 341 Fat. It will need a little practice to tell, by the use of the diet, whether there is an increase of fat in the stool. As the normal amount of fat in the feces varies between wide limits only a considerable excess of fat can be detected. Remnants of Meat. Normally there should be only microscopic particles of connective tissue and muscle fibre. An excess of either is often visible to the naked eye, but need not be macroscopic to be pathologic. Excess of Connective Tissue indicates insufficient gastric digestion, because such fibrous tissue is only digested by the gastric juice. The meat should be rare, to give this test its full value. If motility is increased, there may be an excess of this in hyper-acidity. Excess of Undigested Muscle Fibre, indicates intes- tinal indigestion and probably means trouble in the up- per part of the small intestine ; but whether the trouble is in the trypsin of the pancreatic secretion, or the activat- ing principle (entero-kinase) of the intestinal juice, or in increased peristalsis, we can only judge from other symptoms. When the gastric juice fails to digest away the frame work of the muscle fibre, giving the intestinal juices no chance to do its work, connective tissue and muscle fibre are often found. This occurs often in acute gastric catarrh. Pathologic Carbohydrate Fermentation means poor starch digestion and indicates, as a rule, disturbance in the small intestine and usually is due to insufficiency of the succus entericus. Pathologic Albumin Fermentation means a large resi- due of albumin in the feces and indicates usually some 342 CLINICAL SIGNIFICANCE OF TEST. anatomical change in the mucous membrane of the small intestine. Pits can be rarely recognized in the stool unless it comes from the lower part of the large bowel ; if it comes from high up in the intestine it is rapidly changed. Blood in the Stools. The presence of blood in such quantities to be visible is considered in Chapter II, so I will only consider the so-called occult blood in the stools. The presence of occult bleeding from the gastro- intestinal tract is a symptom of much importance, pro- viding various sources of error can be eliminated. It has the same clinical significance as visible hemorrhage and its presence is of decided diagnostic value, chiefly in the detection of gastric or duodenal ulcer, or gastro- intestinal cancer, because it occurs with considerably more regularity and frequency in these affections than in any other condition of the gastro-intestinal tract. The value of this sign depends entirely upon the care with which the various sources of error are eliminated, and if the reaction is positive will be of value in the diag- nosis of cancer or ulcer of the gastro-intestinal tract only when sources of bleeding that have no significance are excluded. On the other hand, after repeated examina- tions, occult blood is not found, then cancer or ulcer can be excluded. Since the test is very sensitve (very small amounts can be detected), the chance for error in deter- mining the origin of the hemorrhage is greater than in large and visible hemorrhages. Observations have shown a positive reaction in the feces on the ingestion of 0.5 gms. of blood. It is possible to exclude the source of the blood when in the lower bowel by the use of the procto- TESTS FOR OCCULT BLOOD. 343 scope, etc. Tuberculous ulcer, typhoid fever, hemor- rhoids, fissure and purpura can be . easily excluded ; other conditions, however, e. g. cirrhosis of the liver with slight symptoms may be the cause of error. Bed beets, carmine, swallowed blood from any cause, hemoptysis, epistaxis, menstruation, cirrhosis of the liver, purpura, benign stenosis with stagnation, tuberculous enteritis, cancer of the gastro-intestinal tract, gastric or duodenal ulcer, typhoid ulcer, hemophilia, hemorrhoids, fissure, and fistula of the rectum is a partial list of conditions which may give a positive reaction with the various tests. When testing for occult blood it is best to have the patient on a diet free from meats and meat juices and to give a good sized capsule of charcoal; the first black stool will mark the feces following the meat-free diet. A number of different tests are used for the detection of occult blood ; probably the Weber test, with its various modifications is the one most employed. It is well, how- ever, to use a control test, preferably Klunge's aloin test. If both tests give a positive reaction, there is no doubt but that there is blood in the stools. The latter is not liable to be obscured by bile pigments or chlorophyll, in the ethereal extract, and is extremely delicate. Webber's Test. Take 2 or 3 gins, feces, mix thor- oughly with 20 c.c of water; extract with 20 c.c ether to remove fats. Then use one-third the volume of acetic acid and shake well ; add 10 c.c of ether and shake well. If ether doesn't come to the top soon, add a few drops of absolute alcohol. To 2 c.c of the ethereal extract, add 10 drops freshly prepared tr. guaiac and 10 to 20 drops of ozonized turpentine. Care must be taken that all uten- 344 TESTS FOB OCCULT BLOOD. sils are absolutely clean and free from water. If blood is present, an intense blue color appears, gradually assum- ing a reddish violet tint. Klunge's Aloin Test. Take a small quantity of aloin, mix with 3 to 5 c.c of 70 per cent alcohol. Four to five c.c of acetic acid ethereal extract is tried with 20 to 30 drops of ozonized turpentine and 10 to 15 drops of the aloin solution. If blood is present a bright red color ap- pears which turns to a cherry red on standing. If blood is not present, a yellow color remains for an hour or two, then becomes pink. It may take 15 or 20 minutes to get a positive reaction. Holland's Modification of Webber's Test. Instead of using ozonized turpentine, Holland used sodium per- borate (Sherring) in tablet form; a few drops of the acetic acid ether mixture is placed upon a small piece of tablet of perborate of sodium and a drop or two of the tincture of guaiac is cautiously brought into contact with it, preferably on a white plate. If blood is present, the perborate turns blue in a few minutes and remains blue until the drying of the tincture of guaiac leaves a yellow residue which changes the blue to green. If the propor- tion of blood is small the perborate turns a pale blue, which turns green as the guaiac dries. Benzidin Test. A little benzidin and about 2 c.c glacial acetic acid are shaken up together and set aside for the benzidin to dissolve. A piece of feces the size of a bean is stirred into a test tube about one-fifth full of water ; the tube is plugged with cotton and the suspen- sion of fecal matter is heated to a boiling point over a flame. About 10 or 12 drops of the concentrated benzi- GALLSTONES. 345 din solution are poured into another test tube, from 2.5 to 2 c.c of a three per cent solution of peroxide of hydro- gen added. One or two drops of the boiled suspension of feces is then added to this mixture. If blood is present in the feces, this brownish fluid turns green or blue; the more blood the more the test inclines to blue. The color reaction occurs within two minutes in the presence of blood and turns to a dirty purple in five to fifteen minutes. If there is no blood present the dirty brown color remains unaltered. Fig. 133. Gallstones. Gall Stones. In cases of colicky abdominal pain, the feces should always be examined for biliary concretions. The best way to search for gall stones is to put the feces in a fine sieve and wash the stool with running water from a faucet, if pos- sible. The concretions vary in size from as small as the head of a pin to the size of a pigeon's egg. They may be seen as small crumbling masses or as hard stones presenting an irregular contour or as smooth facets. (Fig. 133.) The larger stones are not passed by the bowel unless perforation has occurred into the intestine. The composition of the calculi varies. Some are composed of cholesterin; some of inspissated bile, and others of cal- careous salts. Those composed of cholesterin are the 346 ANIMAL PARASITES. most common and are somewhat soft and white, greyish, bluish or greenish in color. I think that the consensus of opinion inclines to the belief that the nucleus of the ma- jority of gall stones is clumps of bacteria, either bacilli coli communis or typhoid bacilli, although it may be com- posed of earthy sulphates or phosphates. Calculi which consist largely of biliary pigments are brown in color, hard and heavier than water; those composed of calca- rious salts are generally irregular and rough. Intestinal Concretions, or Enteroliths, are rare. At times their nucleus consists of some foreign body like a fruit seed, upon which calcium and magnesium salts have become deposited. Intestinal Sand is hard, gritty, pale brown to black in color, readily sinks in water, and is usually composed of the salts of calcium magnesium and ammonium. Some- times silica is present. Animal Parasites. Pathologic Forms. Of the protozoa, the amoebae (see Chapter XIII), are the most important in the etio- logy of intestinal disease. It is possible to find amoebae in the stools of perfectly normal individuals, and they increase in number as the stools become more alkaline in reaction. In certain forms of dysentery the amoebae coli occur in the stools in enormous numbers, chiefly embedded in the mucus. They are also found on pathologic exami- nation in the ulcers in the intestines. In examining the stool must be fresh, as the amoebae very rapidly die off in a stool that has been preserved but a few hours. A particle of mucus, preferably blood streaked, is taken PROTOZOA. 347 from a fresh stool and placed on a chemically clean slide or better, a warm stage. In adjusting the cover glass, a horse hair or some similar object should be placed be- Fig. 134. The Amoeba Coli. Clinical Diagnosis: Simon. tween it and the slide, in order not to crush the organisms or interfere with their locomotion. Examine with a low power microscope. They are from 10 to 50 micro-mil- limetres in size. When at rest, their outline is, as a rule, circular or ovoid; but when in motion, they present one or more arm-like prolongations, 'the pseudopods." The protoplasm can be differentiated into a translucent, ho- mogenous ectosarc or mobile portion and a granular en- dosarc containing the nucleus, vacuoles, and granules. (Fig. 134.) As a rule one or two large vacuoles are pres- ent, the edges of which are not infrequently surrounded by fine, dark granules. Balantidium Coli. Another form of protozoon, that is an etiologic factor in certain forms of dysentery is the balantidium coli. This organism is a harmless inhabitant 23 348 WORMS. of the colon of the pig, and it is supposed, is transferred to human beings through sausages. (Fig. 135.) The para- site is of oval shape, 60 to 100 microns long and 50 to 70 Fig. 135. Balantidium Coli. 2. 1 and 2 stages of division. 3 Conjugation. (After Leuckart.) Progressive Medicine, December, 1905. broad, and is covered with cilia that are in rapid motion when the organism is alive. Ectosarc and endosarc are sharply differentiated. The endosarc is granular and contains a kidney shaped nucleus, generally two contrac- tile vacuoles and granular detritus. Motion is so rapid that it cannot be followed under the microscope. The protozoon dies very quickly and undergoes fragmenta- tion. There are other forms of protozoa, but their role in the etiology of intestinal diseases is not definitely settled. Worms. The diagnosis of helniinthiasis from the stools may be very easy or it may require considerable painstaking re- search. If segments of the taenia pass in the stools, the diagnosis is quite evident. In other cases, a diagnosis can only be made by finding the ova in the feces. To examine for the ova, take a small amount of feces from WOEMS. 349 different parts of the stool, dilute it very much with sterile water and centrifuge repeatedly. After each cen- trifugalization, the supernatent dirty water is thrown away and fresh water is added, the whole shaken up and again placed in the centrifuge, this to be repeated five or six times. In this way all bacteria, free coloring mat- ter, light vegetable matter, etc., are gotten rid of and only heavier particles including any ova that may be present, will remain and can be easily and satisfactorily examined under a low power of the microscope. There is the left no obscuring cloud of bacteria or fine granular debris, but instead each ovum, or muscle fibre, or crystal stands out sharp and clear. Fig. 136. Ascaris Lumbricoides. a, The Worm; b, Head; c, Egg; a, half natural size; b, slightly magni- fied; c, eye piece I, objective 8a. Reichert. Clinical Diagnosis: vori Jaksch & Cagney. 350 NEMATODES. Nematodes. Nematodes are round worms. Those found in the human being are: 1. Ascaris Lumbricordes is the most common parasite of the human intestinal canal. They are found chiefly in the small intestines but may find their way into the stomach, the bile passages, or out at the anus. Clumps of them have been known to cause intestinal obstruction. Fig. 137. Oxyuris Vermicularis. a, sexually mature female; b, female filled with eggs; c, male. Magni- fication, 10. (After Heller, from Ziegler.) NEMATODES. 351 The worm is cylindrical, the male being from 10 to 25 c.m. in length, the female from 25 to 40 c.m. The head consists of three projections or lips, which are provided with suckers and fine teeth. The tail end of the male is rolled up on its ventral surface like a hook and is pro- vided with papillae. The genital aperture of the female is situated directly behind the anterior third of the body. The eggs are yellowish brown in color, almost round, and measure 0.06 mm. by 0.07 mm. in size. They are sur- rounded by an irregular albuminous envelope which is covered by a tough shell ; the contents are coarsely granu- lar. (Fig. 136.) 2. Oxyuris Vermicularis. (Common thread worm, teat worm, pin worm, etc.), is a very frequent parasite, especially in young children, often passing from the anus into the vulva in female children and setting up con- siderable irritation in the vagina. The male is 4 mm.; the female 10 mm. long. At the head three lip-like pro- Fig. 138. Oxyuris Vermicularis. I. Oxyuris vermicularis ; a, Male ; b, Female ; natural size. 2, Magnified. Urine and Feces in Diagnosis: Hensel, Weil & Jelliffe. 352 NEMATODES. jections with lateral cutieular thickenings may be seen. The tail of the male is provided with six pairs of papillae and the female with two uteri. The eggs are 0.05 by 0.02 to 0.03 mm. in size, and covered with a membrane show- ing a double or triple contour. In the interior, which is coarsely granular, the embryo are contained. The ova do not occur in the feces. (Figs. 137-138.) Anchylostomum Duodenale, or Dochimus Ditodenn- lis, or Strongylus Duodenalis is generally described in America as Uncinaria. It was formerly supposed that this parasite was found only in the Old World and only brought into this country, but it has been demonstrated that there are many endemic cases in our Southern States. Fig. 139. Anchylostoma Duodenale. a, Male (natural size). b, Female (natural size). c, Male (magnified). d, Female (magnified). c, Head (eyepiece II, objective C, Zeiss). Eggs. f, von Jaksch & Cagney. NEMATODES. 353 There are certain differences between the American and Old World parasite. Stiles, in Bulletin No. 10 Hygienic Laboratory, U. 8. Public Health and Marine Hospital Service, gives the following description: Uncinaria duodenalis -"The Old World hook worm: Body cylindrical, somewhat attenu- ated anteriorly; buccal cavity with two pairs of ventral teeth curved like hooks, and one pair of dorsal teeth directed backward; dorsal rib not projecting into cavity. Male 8 to 11 mm. long, caudal bursae with dorso-median lobe and prominent lateral lobes united by a ventral and slender. Female, 10 to 11 mm. long; vulva at or near Dosterior third of body. Eggs ellipsoid 52 to 60 micro- millimetres by 32 micromillimetres laid in segmentation. Development direct without intervening host." (Fig. 139.) Uncinaria Americana "The New World hook worm of man, body cylindrical, somewhat attenuated anteri- orly, buccal capsule with a dorsal pair of prominent semi- lunar plates or lips and a ventral pair of slightly de- veloped lips of same nature ; dorsal conical median tooth projects prominently into buccal cavity. Male 7 mm. long, caudal bursae with short dorso-median lobe which often appears as if it were divided into two lobes, and with prominent lateral lobes united ventrally by an indis- tinct ventral lobe ; common base of the dorsal and dorso- lateral rays very short; dorsal ray divided to its base, its two branches being widely divergent, and their tips being bipartite; spicules long and slender. Female 9 to 11 mm. long; vulva in anterior half of body but near equator. Eggs ellipsoid, 64 to 76 micromillimetres long by 36 to 40 micromillimetres broad, in some cases parti- 354 NEMATODES. ally segmented in utero; in others containing a fully developed embryo oviposited." The eggs of the Ameri- can species are much larger than those of the Old World species. The eggs have a transparent shell with a lineal- contour and are often found in enormous quantities in the feces. A rather peculiar fact that the ova of uncina- ria, although sticking closely to the glass slide, do not seem to adhere to any of the other constituents of the stool. When a drop of washed sediment feces is allowed to remain on the slide for a few minutes and then gently immersed in water and examined microscopically, the eggs are found adhering to the slide and all else has been washed away. In suspected cases where the diagnosis is difficult, a full dose of thymol may make it clear ; caus- ing the appearance in the stool of the parasite which ap- pears as a thread-like body, a half to three-quarters of an inch long, grayish red in color. Its habitat is the jejunum and duodenum. Infection takes place through contaminated drinking water. For persons who are not in a position to make a micro- scopic examination, the blotting paper test will be found very useful. To make the test use only fresh feces. Place an ounce or more of the stool on a piece of white blotting paper, allowing it to remain for 20 to 60 minutes ; remove the feces and examine the color of the stain. In about 75 per cent of the cases of medium or severe uncinariasis. the stain is a reddish brown resembling somewhat a blood stain. In making this test on anemic patients, hemorrhoids must be excluded. Trichocephalus Dispar, or "Whip Worm," frequent in most parts of the world, gets its name from being NEMATODES. 355 formed like a whip, the lash end being the head end, while the tail end is very much thicker. The male meas- ures 46 mm. and the female 50 mm. in length. The eggs Fig. 140. Trichocephalus Dispar. a. Male; b. Female; c. Eggs; a. b., slightly magnified; c. (eye piece II, objective 8 a, Reichert.) von Jaksch & Cagney. are brownish in color 0.05 by 0.06 mm. in size, presenting a double contoured shell with a depression at each end, closed by a lid. The contents are coarsely granular. Its habitat is in the cecum; the living worm is rarely found in the feces. (Fig. 140.) Trichina Spiralis. The male is 1.5 mm. in length, and the female 3 mm. The male has four prominent pa- pillae, situated between the conical protuberances at the extremity. The female's sexual organs consist of a tubular ovary which is placed at the hinder part of the body and a tubular uterus with which the ovary communi- cates in front. Impregnation takes place in the intes- tine. The eggs develop into embryos while still in the 356 NEMATODES. uterus, and the newly born parasite almost immediately perforates the intestine and becomes embedded in tke muscles of its host. The mode of infection is through Fig. 141. Trichinae. a. Male, and b. Female Intestinal Trichinae, slightly magnified ; c. Trichina of muscle (eye-piece III, objective IV, Reichert.) von Jaksch & Cagney. imperfectly cooked pork. Rarely is the parasite found in the stools. In suspected cases an anthelmintic may cause the expulsion of the mature worm in the stool. Eosino- philia is a constant accompaniment of the presence of trichina. (Fig. 141.) Anguillula Intestinalis, is 2.25 mm. in length and 0.04 mm. in thickness at its middle. It has a triangular mouth closed by three lips. Its vulva lies at the junction CE3TODES. 357 of the middle with the posterior third. Its habitat is the small intestines. The eggs resemble those of anchylo- stoma duodenalis but are longer, more elliptical and Fig. 142. Anguillula Stercoralis. a. Female; b. Male; c. Head (eye-pice II, objective 8 a, Reichert.) von Jaksch & Cagney. pointed at the poles. In recent stools the larvae alone can be seen. When sexually mature, it is known as an- guillula stercoralis; the body is round; it shows faint traces of transverse striation. The head is the form of a blunt cone and sessile on the body, and is furnished with two lateral jaws, each bearing a pair of teeth. The male is 0.88 mm. and the female 1.2 mm. long. Little is known concerning the manner of infection. Thayer reported the first case of infection by this worm in the U. S. (Fig. 142.) Cestode Worms. Cestodes are popularly known as tape-worm. Externally they are long, flattened seg- mented worms. The head is derived from the embryo 358 CESTODES. contained in the flesh of the various domestic animals which are used as food. By budding it gives rise to all of the succeeding segments which are morphologically the same, diminishing in size toward the head. Fig. 143, Head of Taenia Solium. Head of Taenia Solium. x45. (Leuckart.) Taenia Solium. The tape worm derived from pork may be two to three meters long. Head quadrilateral, about as large as a pin-head ; it has four prominent suc- torial discs, usually pigmented and between them a rounded elevation which is surrounded with about 26 booklets of different sizes, and is dark in color. This is succeeded by a delicate thread-like neck about one inch in length and unjointed. The segments or proglottedes are short and relatively broad near the neck ; the mature segments' average length is from 9 to 10 mm. and breadth 6 to 7 mm. and contains a uterus having five to seven branches. The ova are round and of a brownish color and surrounded with a thick radially striated membrane ; in their interior the booklets of the embryos can usually 'be made out. (Fig. 143.) Taenia Saginata (Medio Cannulata). The most fre- quent tape worm of Europe and America, infection tak- ing place through measlv beef. It is from 4 to 8 metres CESTODES. 359 long. The head is surrounded with four large and usu- ally black pigmented suckers, but is not provided with' rostellum and is without a circle of booklets. Segments Fig. 144. Taenia Saginata. a. Natural size. b. Head much enlarged. c. Ova much enlarged. Clinical Diagnosis: Simon. 360 CESTODES. are quite thick and opaque, and each is provided with a very much branched uterus which opens laterally. The ova are elliptical in form, of a brown color, and usually enclosed in a distinct vitelline membrane. In the interior the embryos are seen embedded in a brown granular material. (Fig. 144.) Taenia Nana. Occurs rarely in America, mostly in Southern Italy. It is 7 to 15 mm. long. It occurs in large numbers, and is usually located in the lower part of the ileum. It has four suckers and a crown of booklets. Tht segments are of a yellowish color and about four times as broad as long. The uterus is oblong and contains numer- ous ova, having two distinct membranes. In the interior of the egg, may be seen the embryo already provided with five or six booklets. Infection probably occurs from man to man. The parasites may be present in great numbers in the intestines, producing severe nervous symptoms such as epileptic seizures, insensibility, mental derange- ments, etc. II Fig. 145. Head of Bothriocephalus Latus. (Eye-piece III, objective IV, Reichert). a. Seen on edge; b. Seen on the flat; c. Proglottides ; d. Eggs. von Jaksch & Cagney. Bothriocephalus Latus. The longest of the human tape worms has been found in the United States in only a few imported cases. The larvae have been found in CHARACTER OF FECES IN INTESTINAL, AFFECTIONS. 361 various fishes. It is from five to eight metres long and tapers toward both extremities. The largest segments measure 3.5 mm. in length, 10 to 12 mm. in breadth. The head is ovoid, 25 mm. long and 1.0 mm. broad, some- what flattened and provided in each lateral aspect with a groove-like sucking apparatus. The uterus is a slightly convoluted canal. The eggs are ovoid 0.07 mm. by 0.045 mm. and possess a thin brown capsule and open by a small lid at one end. This parasite may be the cause of severe anemia. (Fig. 145.) Character of Feces in Certain Intestinal Affections. Acute Intestinal Catarrh. This follows the inges- tion of excessive quantities of normal food or tainted food, beer and certain poisons, acids or alkalies, arsenic, corrosive sublimate, etc., when taken in proper quanti- ties ; also find it in cholera nostras, typhoid fever, severe malaria, also in diseases of heart, lungs and liver due to disturbance in circulation. The frequency of the stools depends largely upon the seat of the lesion ; involvement of the large intestine, especially the transverse and de- scending colon causing the bowels to move more fre- quently than trouble higher up. There may be from 10 to 15 passages a day. On the other hand, isolated catarrh of the small intestine may exist without giving rise to diarrhoea. The stools at first are semi-solid but rapidly become liquid, often foul smelling and associated with gas. The higher in the bowel the lesion, the more odor and gas. The color varies from a light to a dark brown. If the trouble exists in the small bowel only, the stools are firm, formed, and contain particles of hyaline mucus 362 CHARACTER OF FECES IN INTESTINAL AFFECTIONS. visible only upon microscopic examination. It usually contains particles of undigested food. If the colon is affected, the stools are loose. Extensive involvement of the colon is usually accompanied by mucus un large quantities. Chronic Inflammation of the Intestine. May follow an acute attack or may follow some of the infectious dis- eases. Diarrhoea usually alternates with constipation. Rarer are continuous diarrhoea or constipation. The feces present the same characteristics as the acute inflam- mations. Diphtheritic Enteritis. Always diarrhoea, often with tenesmus. Stools fluid, with occasional passage of formed feces. They consist mostly of pus, blood and mucus, and some necrotic tissue may be found. Muco-Membranous Colitis. No frequency in num- ber of stools; may have constipation. Stools are com- posed largely of tough leathery mucus which may present casts of the bowel. This may be transparent or gray and semi-opaque, or may be brown (from fecal matter), or red (blood). Cholera Nostras. An infectious disease affecting both the stomach and bowels. The stools are first fecu- lant, but soon become colorless and more and more watery until they resemble the so-called "rice water" stools of Asiatic Cholera, and contain serum albumin and mucin. Dysentery. Stools are large and frequently com- posed of pus, mucus, and blood, fluid or semi-fluid, may find necrotic masses of mucous membrane. Amoebic Dysentery. Stools are frequent, fluid, and may contain large amounts of mucus, frequently stained CHARACTER OF FECES IN INTESTINAL AFFECTIONS. 363 with blood; reaction always alkaline. Microscopic ex- amination of the fresh mucus shows epithelial and red blood cells and the amoeba. Carcinoma of the Small Intestine. The stools of which have no distinctive feature. Carcinoma of the Rectum and Sigmoid is taken up else- where in this volume. (Chapter XVI.) INDEX A. Abscess, ano-rectal, chapter on 137, 189, 305, 322 classification 138 general etiology 137 ischio-rectal 146, 154, 165, 166 diagnosis 148 etiology 147 symptoms 147 treatment 149 incision 149 sub-mucous 142, 154, 166, 617 diagnosis 143 examination 142 symptoms 142 treatment 143 incision 145 sub-tegumentary 140, 154, 165 diagnosis 142 etiology 141 examination 142 symptoms 141 treatment 144 tegumentary 138, 165 diagnosis 140 etiology 138 treatment 140 ABLER, L. H., Jr Ill Albolene, liquid, 89, 100 101, 128, 168, 203, 208, 228, 232, 289 ALLBUTT 249, 250 Alligator forceps 67 Amoeba coli mitis (see para- sites) 251, 346 dysenteriae (see parasites) . . 248, 249, 346 Anal canal 18 Anal Fissure (see Fissure in Ano) 122 Anal Fistula (see fistula in ano) 152 Anal Papilla (see Papillae anal) 209 Anatomy, chapter on 17 Anchylostoma duodenale 352 ANDREWS 352 Anemia 40, 181, 314 Anesthesia local (see local anesthesia) . 295 general (see nitrous oxide) . . 158 Anguillula intestinalis (see par- asites) 356 Animal parasites (see para- sites Ano-coccygeal ligament 27 Anoscope (see Hirschman- Kelly) Anoscope-Hirschman's 62, 156 Anoscopy 64, 186 Anus 17 dilatation (see dilitation- sphincter) 18, 20 eversion of 54 fissure of (see Fissure) 122 ulcer of (see Ulcer) 122 Appendicostomy 282 Appendix vermiform 263 Appetite, loss of 40 Artery (see Frontispiece) hemorrhoidal inferior 29, 30 middle 30, 31 superior 30 iliac, internal 31 mesenteric, inferior 30 365 366 INDEX. Artery, pudic, internal 31 sacral, middle 30 vesical SO Atresia ani vaginalis complete 74, 76 incomplete 75, 76 Ascaris lumbricoides (see worms) 349 Auto-intoxication 40, 98 AYERS 239 B. BALL, SIR CHARLES.. 26, 116, 119 BECK, EMIL G 1G9 Bismuth paste injections 169 Bleeding 34, 98, 126, 180 187, 188, 209, 222, 235, 259, 314 Blood in the stool (see bleed- ing) 342 test for 332, 342 Holland's 344 Klunge's aloin 344 Webber's .- 343 Bothriocephalus latus (see par- asites) 360 Bougie, Wales 69, 311, 321 Bovinine .v 132, 162 C. Canal, anal 18, 126 Cancer, rectal 36, 181, 188, 314, 315, 316, 317, 318, 319, 321 Carcinoma, rectal (see cancer). Cauterization of hemorrhoids.. 191 electro of hemorrhoids 191 CETTI 328 Chloretone 112, 190, 297 Clamp and cautery 204 Clover's crutch 56 Cocain 296 Coccyx, examination of 58, 59 Colitis (see Proctitis and sig- moiditis) 327 Colostomy . 321 Columns of Morgagni 23 Commissures, ana'. . . . .123, 124, 126 Concretions (see impaction).97, 221 removal of (see Foreign Body) 325, 346 Condylomata (see Warts) 37, 189, 231 Congenital defect 74, 76 CONLEY, H. P 283 Constipation, chapter on 77, 38, 178, 221, 235, 313- causes 80 diagnosis 83 treatment 84 rectal massage 86 Corrugator Cutis Ani 18 CORSONS, E. A 282 COUNCILMAN and LE FLUER 239, 248, 258, 263 CRAIG 269 CRIPPS, HARRISON.. .28, 110, 169 CRISLER, .1. A 283 Cropology (see Feces, exam- amination of) 326 Cryptitis, chapter on 209, 218 symptoms 218 treatment 219 Crypts of Lieberkuhn 235 Crypts of Morgani 18, 20, 124, 147, 168, 189, 209, 213, 307 D. Defecation, disturbances of (see abscess, constipation, fissure, hemorrhoids, im- paction, rectal valve). physiology of 78, 326 DE VILBISS' Speculum... 145, 167 spray tube 227 Diarrhoea 38, 98, 166, 222, 231, 244, 316, 327 Diet. in constipation 81 in dysentery 266 INDEX. 567 Diet, in fissure 127 in hemorrhoids 208 test 327. 331 Digestion, disturbance of 40 Digital examination 48, 135 Dilatation of sphincters .54, 104, 130, 186, 193, 199 local anesthesia for 299 Discharge 38, 98 113, 114, 154, 166, 168, 209 222, 235, 259, 260, 314, 332, 342 Douglas, pouch of 28 Dysentery, chapter on 238 distribution 239 general etiology 239 history 238 acute catarrhal 243 diagnosis 245 pathology 243 prognosis 245 special etiology 243 symptoms 244 amoebic 248 case reports 260, 261 complications 263 diagnosis 264 etiology 248 pathology 253 prognosis 264 sequelae 263 treatment 265 diet : 266 intestinal antiseptics 270 irrigations 274 laxatives 269 prophylaxis 265 --remedial 267 chronic amoebic 279 diphtheritic 245 complications 247 diagnosis 247 etiology 246 pathology 246 symptoms 246 Dysentery, treatment 247 secondary diphtheritic 247 prognosis 248 symptoms 248 treatment 248 E. Elevations 37 Enema 61, 111 Entamoeba Histolytica 248, 250, 252 Eucain (see Local Anesthesia) .....114, 115, 296 Eversion of anus. . . . . . .54, 55, 56 Exaggerated lithotomy position : 72, 186 Exaggerated Sims' position 281 Examination, Chapter on... 41, 313 abdomino- rectal (see Recto- abdominal) 57 abdomino-vagiual 58 anoscopic (see Anoscopy) ... 64 digital 49, 52 of feces (see Feces) 326 protoscopic (see Proctos- copy) 67 sigrnoidoscopic (see Sigmoid- oscopy) 73 vagino-rectal 54 External Sphincter (see Sphinc- ter Ani External) 18 F. Fecal impaction 97 Feces (see Stools, defecation) 326 character of in intestinal af- fections 301 acute intestinal catarrh (see Proctitis) 361 amoebic dysentery (see Dys- entery) 362 cholera nostras 362 chronic intestinal catarrh (see Proctitis) 362 diphtheritic enteritis 362 368 INDEX. Feces (see Stools, Defecation). dysentery (see chapter on disentery) 362 muco - membranous colitis (see sigmoiditis) 362 chemical examination of 336 fermentation test 336 sublimate test 336 clinical examination of, Chapter on 326, 331 macroscopic elements 329 misroscopic elements. 330 examination 333 normal 326, 327, 328, 329 pathologic elements 332 clinical significance of tests. 339 concretions in 346 estimation of lost albumen . . 338 gallstones in 345 location of 53 parasites in (see Parasites) . 346 tests for blood in 344 Benzidine test 344 Holland's test 344 Klunge's test 344 Webber's test 343 Finger cot 50 Fissure in ano, Chapter on.... 122, 187, 209, 219, 235, 306, 314 after care 132 diagnosis 126 etiology 123 --symptoms 126 treatment 126 surgical 130 excision 133, 134 author's operation 133, 134 incision 130 multiple 123 Fistula in ano, Chapter on... 142, 146, 152, 306, 323 classification 153 etiology 152 blind external . . 164 Fistula in ano, diagnosis 166 symptoms 166 treatment 166 blind internal 166 diagnosis 167 symptoms 166 treatment 167 horse shoe 153 multiple 153 simple complete 154 after care 162 diagnosis 154 symptoms 154 treatment 158 excision 159 author's operation 160 incision 159 injection of bismuth paste. 160 ligature operations 162 sub-muco-cutaneous 169 sub-mucous 168, 169 tuberculous 171 diagnosis 171 symptoms 171 treatment 172 Folds, Houston's (see Rectal valves) 22 Forceps, alligator 67 Foreign body in rectum 40, 329 local anesthesia for removal of 308 Formalin-Boric solution 273 Formulae 90, 108, 109, 110, 111, 129, 132, 191, 194, 200, 201, 271, 273, 274, 277 FRANCK 192 G. Gallstones (see Impactions, foreign bodies 345 GANT, S. G 29, 92, 111 H. HAMILTON, E. A 114 HARRIS, H. F...239, 256, 275, 282 INDEX. 369 Hemorrhage (see Bleeding). Hemorrhoidal arteries (see Ar- teries frontispiece) 29, 30, 31 forceps, author's 196 nerves (see Nerves) 30, 32 veins (see Veins frontis- piece) 31 Hemorrhoids, Chapter on 173, 35, 37, 84, 209, 236, 288, 304, 318, 323 classification 175 external 175 integumentary 175, 178 treatment 206 thrombotic 175, 176, 183 treatment 205, 305 varicose 176 internal 176, 183 general etiology 177 capillary 176 granular 176 varicose 176, 177 diagnosis 184 etiology 177 symptoms 180 treatment 190 cautery 191 excision 195 author's operation.. .197, 199, 201 injection 191 palliative 190 sub-mucous excision 203 surgical general 193 int erno-external . 179, 180, 182, 198 treatment 198 HILTON, white line of 22 HIRSCH, A 239 HIRSCHMAN, L. J. anoscopes 62, 65, 66, 157, 168 bloodless operation for hem- orrhoids 197, 199,201 blunt ligature carrier 198 HIRSCHMAN, L. J. dilating rectal massage bag 86, 87 hemorrhoidal forceps 196 method of rectal massage... 85 modification of Ball's opera- tion 117 operation for exision of fis- tula 160 for excision of fissure. . . .133, 134 for rectal valvotomy. .92, 94, 95 proctoscopes 70, 92, 308 rectal retractor 197 rectal scissors 94, 168 rectal spray tube 225 sigmoidoscope 73 valvotomy needle 92 HOLL 27 Holland's test 342 HOUSTON (see Rectal valves) 22 folds of (see Rectal valves) 22 valves of (see Rectal valves) 22 I Ichthyol 112, 128, 129, 228, 232, 234, 279 Ilio-coccygeus (see Levator ani 26 Impaction fecal, Chapter on. 97, 221 causes 97 diagnosis 99 symptoms 98 treatment 99 Indigestion 222, 231, 259 Inspection, External 48 internal (see Anoscopy, Proc- toscopy, Sigmoidoscopy) 61, 64 Instruments for anoscopy 64 inspection 100 local anesthesia 298 office treatment of dysen- tery 272 proctoscopy 68 Sigmoidoscopy 73 370 INDEX. Instruments surgical treatment of fis- sure 127, 133, 134 fistula 158, 160, 1G6, 167 hemorrhoids 191, 199 pruritus 114, 115 ; 117 Intermural abscess (see Ab- scess 142 Internal Sphincter (see Sphinc- ter ani, internal) 22 Iodide of mercury 48 Ischio-rectal abscess (see Ab- scess) 60, 146 fossa 28 Itching (see Pruritus ani 36, 107, 154, 166 J JELKS, J. L 227, 238 rectal tube 227, 232, 274 K KARTULIS 239, 271, 272 KELLY, Anoscope 65, 67 leg holder 56 sigmoidoscope 73 KELSEY, CHARLES 110,191 Klunge's test 344 Knee-elbow position 63 Knee-shoulder position 63, 67, 186, 278 KRAMERIA, extract of 226, 232 KRAUSS, WM 261 L Lancet-Clinic 169 Lateral Ligaments 27 Lateral position (see Sims' po- sition) 51 LE ROY, LOUIS.. 279 Lesser Sphincterian Nerve.... 20 Levator-ani muscle 24 LIEBERKAUHN 235, 246 Ligaments of rectum 27 ligature carrier, blunt pointed, ; Author's . 198 Ligature operation for Fistula (see Fistula) 162 Ligature, rubber (see Valvoto- my, Fistula, Stricture) .... 322 Light, Electric head 43 Linea-dentata 18, 20 Lithotomy position 55, 56, 58, 100, 144, 148 Local anesthesia, Chapter on 295, 20, 54, 100, 114, 117, 130, 133, 140, 143, 144, 145, 149, 158, 159, 160, 167, 193, 207 amount of distension neces- sary for 301 - -anesthetics used 296 apparatus necessary 298 limitation of, Chapter on. ... 312 point of puncture for 300 position of patient for 299 preparation of patient for. . . 29s* technique for dilatation of sphincters under 303 operating for acute throm- botic hemorrhoids 305 operating for external hem- orrhoids 304 operating for fissure in ano. . 306 operating for fistula in ano.. 306 operating for hypertrophy of anal papillae 307 operating for hypertrophy of rectal valves 308 operating for internal hemorr- hoids 19.3 operating for peri-anal ab- scesses 305 operating for posterior proc- totomy 310 operating for removal foreign bodies 308 operating for removal peri- anal growth 309 Lubricant , . . 50, 277 INDEX. 371 Lymphatic glands: inguinal 21 lumbar 32 pre-sacral or post-rectal 32 Lymphatic vessels 31 M MAC MILLAN, J. A 85 Malformations of anus, Congen- ital 74, 76 MARTIN, T. C 22, 69, 92 Marginal abscess (see Abscess, sub-tegumentary) 140 Massage, Rectal, Author's method of 85, 101 MAUREL 327 MCGREGOR 239 Menstruation, Disturbances of 39 Methylene blue 64 MEYER, W 282 Middle hemorrhoidal vessels.. 27 Milk of Bismuth 64 Milk of Magnesia 64 MOREST1N 32 MORGAGNI, Columns of 23 crypts of 18, 20. 124 MUSGRAVE 239, 258, 263, 275 N Nausea 40 Nerve, fifth sacral 20, 32 fourth sacral 21, 32, 116 internal pudic 20 lesser sphincterian 20, 32 anesthetization of 302 sixth sacral 20, 32 sympathetic 32 third sacral 20, 32, 116 Nitrous oxide 100, 130, 291, 322 Non-surgical treatment of fis- sure 127 fistula 162 hemorrhoids 190 proctitis and sigmoiditis 223, 231 Non-surgical treatment of fis- sure, ulcer 162 Nux-vomica . 89 Obstipation (see rectal valve, constipation), Chapter on. . 77, 90, 98, 38 etiology 90 treatment 92, 93 Office treatment of rectal dis- eases, Limitations of 312 Oil, White petroleum (see Al- bolene) 89 Operating room equipment.... 41 OSLER, WILLIAM 239, 248, 275 Oxyuris vermicularis (see par- asites, pin worms) 103, 350 Pain.. 33, 39, 126, 141, 143, 147, 154, 182, 235, 244 259 Palpation, bimanual 60, 148 recto-abdominal 57, 99 Pancreatin 89, 232, 236 Papilla, Anal, Chapter on 209, 20, 189, 211, 214, 307 hypertrophy of 211 diagnosis 214 examination 214 symptoms 217 treatment 219, 220, 307 Parasites 103, 221, 248 animal in feces 346 cestodes 357 bothriocephalus latus 360 taenia nana 360 taenia saginatta 358, 359 taenia solium 348 nematodes 350 anchlyoptoma duodenale 352 anguillula intestinalis 356 ascaris lumbricoides 103, 349 372 INDEX. Parasites, oxyuris vermiculars (see pin worms) 350, 351 trichina spiralis 355 trichocephalus dispar 354 uncinaria Americana 353 protozoa 347, 346 amoeba (see Dystentery) .... 346 balantidum coli 347, 348 PENNINGTON, J. R 92, 169, 170 Peri-anal abscess (see Abscess) 137 Peristalsis 24, 78 Peroxide of hydrogen 64, 100, 109, 157, 282 Physiology of defecation 78, 326 Piles (see Hemorrhoids) 173 Pin worms (see oxyuris vermi- cularis) 40, 103, 109, 351 Plicae transversalis recti (see rectal valves) 22 Polypus, Chapter on... 125, 188, 288 classification 209 diagnosis 210 symptoms 209 treatment 210 Position, Exaggerated lithot- omy 72, 186 exaggerated Sims' 281 knee-shoulder ......63, 67, 186, 278 lateral (see Sims' 48 lithotomy (see Lithotomy) . . 55 rectal massage 88 squatting 59, gi Posture, Characteristic in rec- tal disease 141 sitting, characteristic 45 Probe 65, 66, 158, 167 Proctitis, Chapter on.. 221, 187, 167 acute 221 diagnosis 223 etiology 221 symptoms 222 treatment 223 chronic . 229 Proctitis, atrophic 234 pathology 234 symptoms 235 treatment 236 general etiology 229 hypertrophic 230 diagnosis 231 pathology 230 symptoms 230 treatment 231 Proctoscope 68, 92, 308 Proctoscopy (see knee-shoulder position)... 67, 69, 181, 186, 278 without instruments 68, 99 Proctotomy, Local anesthesia.. for 310 Prolapse of anus 284 Prolapse of rectum 35, 189, 209, 222, 324 classification 284 concealed 286, 298 in children, Chapter on 284 diagnosis 287 etiology 286, 287 prophylaxis 291 symptoms 297 treatment 288 actual cautery 293 cauterization with nitric acid 291, 292 Prolapsing internal hemorr- hoids (see Hemorrhoids) . . 184 Protrusions 37, 188, 189 Pruritus ani (see Itching), Chapter on 102, 126, 165, 183, 218, 231, 235 appearance of parts in... 105, 106 -characteristics of 107 etiology 102 treatment 108 Ball's operation 116 general surgical treatment 114 Hamilton's operation 114 Pubo-coccygeus (see Levator ant) 26 INDEX. 373 Pubo-rectalis (see Levator ani- 26 Pus (see Abscess, Discharge, Fistula, Proctitis). .38, 98,342 Q Quadrants of anus.. 46 Record card (Author's) 47, 48 Rectal (see Rectum) : chambers 22 dressing 114 retractor (Author's modified) 197 scissors, Author's angular. . . 94 spray 100 spray tube, Author's 225 stricture (see Stricture, Rec- tal) 310, 321, 322 tube 100, 227, 232, 238, 274 ulcer (see Ulcer, rectal) 98 valves 22, 23, 69, 71, 90, 91, 223, 277, 308, 322 valvotomy (see Valvotomy).. 92 Recto-abdominal palpation 57 Recto-Vesical pouch 28 Rectum (see rectal) anatomy of 20 prolapse of (see Prolapse) . . 284 relations of 28 ulcer of' (see Ulcer) 98 Restlessness 40 Ring worm 103, 109 Rubber ligature (see Fistula, Proctotomy, Valvotomy) . . 322 S Sacral backache. . .39, 147, 222, 235 Scabies 103, 109 SCHMIDT 331 Scissors, Author's angular.. 94, 168 sharp, curved 114 Scybala 231, 245 Sentinel pile (see Fissure) .124. 126 SHIGA 239, 246 Sigmoid colon (see Chapter XII) 22, 28 Sigmoiditis 221 acute 221 etiology 221 symptoms 222 treatment 223 chronic 229 general etiology 229 symptoms and treatment see Proctitis, Chronic) 230, 231 Sigmoidoscope 73 Sigmoidoscopy (see Exaggerat- ed Lithotomy position) 73, 99, 186 Silver, Nitrate of. .112, 129, 234, 279 bims' position 48, 51, 87, 100, 117, 142, 144, 148, 185, 276 Spasm 34, 142, 255 Speculum: author's fenestrated (see an- oscope) 62, 65 bivalve, rectal 68 DE VILBISS 145, 167 Sphincter Ani External (see di- latation) 18, 124, 150, 216 local anesthesia for dilatation of 299 spasmodic contraction of.... 142 Sphincter ani internal 22 Sphincter recti (Pubo-rectalis) 26 Squatting position 59, 61 Steele's Fermentation appar- atus 336 Sterile Water anesthesia 297 Sterilizers, instrument 44 STERNBERG 239 STILES 353 Stools (see Feces) 326 altered 39, 361 STRASBURGER 336 STRAUSS 327 Stricture, Rectal 310, 321, 322 STRONG ...239, 246, 258, 263, 275 Subcutaneous abscess (see Ab- scess) 140, 154, 165 374 INDEX. Submuco-cutaneous abscess (see Abscess) 142, 154, 168, 167 Submucous abscess (see Ab- scess) 142, 154, 166, 167 Submucous tract (see Fistula. Submucous) 167 Subtegumentary abscess (see Abscess) 140, 154, 165 Suppository (see Formulae) . . 130, 159, 194, 271, 274 Symbiosis, Bacteria of (see Dysentery) 251, 252,255 Symptoms calling for rectal ex- amination (Chapter on) . . 33 U Ulcer, Anal, Chapter on 122, 112, 124, 135, 136, 236, 314 excision of 135.. 136 Ulcer, rectal 98, 187, 233, 236, 244, 321 amoebic 253, 255 Uncinaria Americana (see An- chylostoma Duodenale) .... 353 Urination, Frequent painful, Disturbances of 40, 144, 147, 222 Uterine disease 40, 98, 103 Table, Operating 42 Taenia nana (see Parasites) . . 360 saginatta (see Parasites) .... 858 solium (see Parasites) 358 Taka Diastase 89 Tampton, Rectal 85 TEACHNOR, W 85 Technique of examination of anus and rectum, Chapter 41 of use of local anesthesia, Chapter on 295 Tenderness ..34, 140, 141, 143, 148 Tenesmus..9S, 235,244, 247, 259, 316 THEVENOL . 243 THOMPSON 26 r 27 Tract, Submucous see (Fistula, Submucous) ..... 167 Trichina Spiralis (see Para- sites) 355 Trichocephalus Dispar (see Par- asites) 354 Tuberculous fistulae (see Fis- tula) 171 TURCK, F. B 85 TUTTLE, J. P 74, 110, 137, 226, 230, 232, 234, 239, 282 Vagina, discharge from 103 Vaginal rectal examination.... 54 Valves, Semi-lunar (see Crypts of Morgagni) 208 rectal (see Rectal Valves) . . 22 Valvotomy, rectal 90, 283 Author's operation for 93 local anesthesia for 308 needle 92 Veins (see Frontispiece) inferior hemorrhoidal 31 internal iliac 31 middle hemorrhoidal 31 superior hemorrhoidal 31 Vibrator, mechanical. .112, 193, 299 W WAGNER, G. W 326 Wales Bougie 69, 86, 310, 321 WALLIS, F. C 112, 168 ; 219 Warts, Venereal 189 Wasserman test for syphilis... 236 Webber's test 343 AVEIR, R 282 Whitehead operation 204 WOODWARD 238, 240 Worms, Intestinal (see Para- ' sites) 40, 103, 348 Diagnosis and Treatment of Diseases of Women By H. S. Crossen, M. D. Clinical Professor of Gynecology, Medical Department Washington University; Gynecologist to the Washington University Hospital, and Chief of the Gynecological Clinic ; Consulting Gynecologist to the Bethesda Hospital, St. Louis Female Hospital, and St. Louis City Hospital. 816 Pages. 700 Illustrations. Price: Cloth $6.00. One-half Morocco $7.50 Sent anywhere prepaid, upon receipt of price. CONTENTS. Chapter I. Gynecologic Examination Methods. Chapter II. Gynecologic Diagnosis. Chapter III. Gynecologic Treatment. Chapter IV. Diseases of External Genitals and Vagina. Chapter V. Lacerations and Fistula of Pelvic Floor, Perineum, External Genitals and Vagina. Chapter VI. Inflammatory and Nutritive Diseases of the Uterus. Chapter VII. Displacements of the Uterus. Chapter VIII. Fibromyoma of the Uterus. Chapter IX. Malignant Disease of the Uterus. Chapter X. Pelvic Inflammation. Chapter XI. Other Affections of Fallopian Tubes, Peritoneum and Connective Tissue. Chapter XII. 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GOLDEN RULES OF SURGERY: Asepsis. Genito-Urinary. Nose. Anesthesia. Operations. Goitre. Abscesses. Joints. Shock. Abdomen. Ear. Oesophagus. Appendicitis. Erysipelas. Pelvis. Aneurysm. Gangrene. Rectum. Artery Bleeding. Hand and Foot. Spine. Burns. Moist Dressing. Throat. Breast. Mouth. Veins. Can Minor Surgical Operations Be Done in Office? Death Following Minor Surgical Operations. Fractures and Dislocations. Therapeutic Hints. Irrigation Drainage of Abdominal Cavity. Minor Surgical Operations. Stomach and Intestines. C. V. Mosby Medical Book and Publishing Co, Grand Ave. and Olive Street., St. Louis, Mo. Golden Rules of Dietetics By A. L. BENEDICT, A. M., M. D. Consultant in Digestive Diseases, City and Riverside Hospitals and Attendant in same; Mercy Hospital, Buffalo; Member of the Academy of Medicine and of American Gastro-Entrological Association, etc. ; Author of Practical Dietetics. CONTENTS. Part I. Chapter I. Physiologic Chemistry. Chapter II. 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A VERY YOUNG OVUM IN SITU Dresden Authorized Translation By W. H. VOGT, A. M., M. D. Obstetrician and Gynecologist, Lutheran Hospital, St. Louis, Mo. 65 Pages Text. 35 Pages Lithographic Illustrations in Colors Price, Cloth $3.50 Publisher's Announcement The importance of an understanding of embryology is becoming more and more apparent. The student now realizes that anatomy is much better understood where it is worked out from the standpoint of embry- onic development than where it is learned in its crude state in the dissecting-room. The surgeon realizes that he can better grasp the relationship of structures when he is familiar with their formation from the embryo. The scheme of development as worked out by Leopold represents the latest work along this line. The work is most scientific and cannot fail to interest all who are seeking the fundamental truths of embryonic development. THE C. V. MOSBY MEDICAL BOOK AND PUBLISHING CO. Grand Avenue and Olive Street, :: St. Louis, Missouri Examination of The Ear By SELDEN SPENCER, A. B., M. D. Instructor of Otology in the Washington University Medical Department, St. Louis, Mo. With an Introduction By H. N. SPENCER, M. D., LL. D. Professor of Otology, Medical Department Washington University, St. Louis, Mo. 67 PAGES OF TEXT 5 FULL PAGE PLATES 12 OTHER ILLUSTRATIONS PRICE $1.00 CONTENTS: Chapter I. Methods of Procedure (General Consideration). Chapter II. The External Ear. Chapter III. Diseases of the Canal. Chapter IV. The Middle Ear. Chapter V. The Middle Ear (Continued), Non-Suppurative Conditions. Chapter VI. The Middle Ear (Continued), Post-Suppurative Conditions. Chapter VII. The Middle Ear (Continued), Suppurative Conditions. Chapter VIII. The Middle Ear (Continued), Purulent Otitis Media. Chapter XL The Middle Ear (Continued), Purulent Otitis Media. Chapter X. The Middle Ear (Continued), Operations in Chronic Purulent Otitis Media. Chapter XL The Internal Ear. 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Hypnotic Suggestive Therapeutics Applied in Medicine, Surgery. Chapter VII. The Psychological Factor in Obstetrics. Chapter VIII. Training the Subconscious Self for Health and Strength. Chapter IX. Correct Diagnosis a Safeguard Against Blunders. Chapter X. Philosophy and Religion and Their Relation to Health. Chapter XL Conservation of Energy, Education and Control of Emotions. Breathing, Relaxation. Dietetics, Exercise, etc. Chapter XII. Roughing It as a Means of Health. Chapter XIII. Are All Specialists Egotists? Chapter XIV. Pensonality as a Factor in Therapeutics. Chapter XV. Environment : Its Influence in Therapeutics. Chapter XVI. Brutality of Frankness: Honesty Imperative. Chapter XVII. Physical and Mental Hygiene; Character as a Resource of Health. Chapter XVIII. Suggestion in Education, Character Building, etc. Chapter XIX. Moral Stamina a Therapeutic Power; The Higher Art in Thera- peutics, and the True Physician. Chapter XX. Self-Mastery as a Fine Art. C. V. Mosby Medical Book and Publishing Co. Grand Ave. and Olive Street., St. Louis, Mo. Office Treatment of Rectal Diseases By R. D. Mason, M. D. Professor of Rectal Diseases in the Creignton University, Omaha, Nebraska. New 4th Edition. 367 Pages. 87 Illustrations. Price $2.50. Tuberculosis of the Nose and Throat By Lorenzo B. Lockord, A. B., M. D. Denver, Colorado Consulting Laryngologist to the Agnes Memorial Hospital, Denver. 504 Pages. 85 Illustrations, 64 of which are colored. Price, $5.00 C. V.Mosby Medical Book and Publishing Co. Grand Ave. and Olive Street., St. Louis, Mo. Arteriosclerosis ETIOLOGY, DIAGNOSIS, PROGNOSIS, PROPHLAXIS AND TREATMENT By L. M. Warfield, A. M., M. D. With an Introduction by H. S. Thayer, Baltimore, Md. 8 ORIGINAL ILLUSTRATIONS. ISO PAGES. PRICE $2.00 PUBLISHERS ANNOUNCEMENT This book is particularly opportune. The rapid pace which Americans are living, the worry and mental strain under which the majority of their time is spent, has made this a nation of arterio-sclerotics. The author has laid stress upon prophylaxis as well as given the most rational treatment known to modern times. The text is embellished with instructive original illustration's. Sent any- where on receipt of price. Diseases of the Skin By A. H. Ohmann-Dumesnil, A. M., M. E., M. D., Ph. D., etc. Formerly Professor of Dermatology and Syphilology in the St. Louis College for Medical Practitioners ; the St. Louis College of Physicians and Surgeons ; the Marion-Sims College of Medicine; Member of the St. Louis Medical Society, of the Missouri State Medical Association, of the American Medical Association, of the 1st, 2d, 3d, 4th, 5th and 6th International Dermatological Congress, etc. THIRD EDITION THOROUGHLY REVISED AND ENLARGED 150 ORIGINAL ILLUSTRATIONS 600 PAGES. PRICE: CLOTH, $4.00. MOROCCO, $5.50 PREFACE This book is not a treatise. The intention has been to make of it a practical guide to the easy recognition of skin diseases, as well as to their successful treat- ment. The remedies which have been recommended are such as may be found in every practician's armamentarium medicinorum. No attempt has been made to write an elaborate work, but rather to furnish, in a clear, concise manner, just that information most desired by medical students and general practitioners. TABLE OF CONTENTS Chapter I. The Skin. Chapter II. Anatomy. Chapter III. Physiology. Chapter IV. Diagnosis. Chapter V. Etiology. Chapter VI. Pathology. Chapter VII. Therapeutics. Chapter VIII. Prognosis. Chapter IX. Symptomatology. Chapter X. Classifications. Chapter XI. Diet in Skin Diseases. Chapter XII. Food Eruptions. Chapter XIII. Appendix. C. V.Mosby Medical Book and Publishing Co, Grand Ave. and Olive Street, St. Louis, Mo. Hand Book of Rectal Diseases BY L. J. HIRSCHMAN, M. D. Professor of Clinical Proctology Detroit College of Medicine and Surgery. 150 Illustrations 400 Pages. Including 2 Colored Plates. Price $4.00. Gonorrhea in Women By Palmer Findley, M. D. Professor of Gynecology in the Medical Department of the University of Nebraska, Omaha, Nebraska. 128 Pages. Royal Octavo. Price $2.00. Chronic Constipation By J. A. McMillian, M. D. Professor of Therapeutics in the Detroit College of Medicine and Surgery, Detroit, Michigan. 257 Pages. Price $2.00. THE C. V. MOSBY MEDICAL BOOK AND PUBLISHING GO. St. Louis, Mo. By E. H. Schorer, B. S., M. D. Assistant Professor of Parositology and Hygiene University of Missouri; formerly Assistant Rockefeller Institute for Medical Research, New York City. 150 Pages. Royal Octavo. Illustrated. Price, $2.00. Emergency Practice and Formulary By T. A. Hopkins, A. M., M. D. ST. LOUIS, MO. 300 Pages. Limp Binding. Gilt Top Pocket Size. Price, $1.00. C. V. Mosby Medical Book and Publishing Co, Grand Ave. and Olive Street., St. Louis, Mo. University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. UC IRVINE LIBRARY 3 1970 01039 5488 WI 600 H669h 1909 Hirschman, Louis J Hand book of diseases of the rectu MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664